📋 Description

• Perform electronic evaluations of escalated cases in accordance with medical policy criteria.

• Execute initial case determinations, review appeals and grievances, and handle additional reviews as assigned.

• Draft clear and concise rationales for notifications to members and providers regarding determinations.

• Engage as a member of the CMDM multidisciplinary team.

• Provide guidance to the multidisciplinary team on cases necessitating physician expertise.

• Proactively manage projects and/or contribute to project teams that require a physician subject matter expert.

⛳️ Requirements

• Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO) is required.

• Minimum of 5 years in Clinical, Direct Patient care (hospital, outpatient, or private practice) is necessary.

• Preferably 1 year of experience in Medical Management within a Health Insurance Plan.

• Must have been awarded Board Certification at least once in a specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association Specialty Certifying Boards.

• Active medical state licensure is mandatory.

• Strong knowledge of the managed care industry is preferred.

🏝️ Benefits

• Competitive salary and comprehensive health benefits.

• Opportunities for professional development and continuing education.

• Supportive work environment with a focus on teamwork and collaboration.

• Flexible work arrangements and work-life balance initiatives.