Medical Physician Job in Glendale, California : CA
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Cardiologist - Physician Advisor
Cardiologist - Physician Advisor Job DescriptionWith over 32 million members covered across 50 states, our client ensures delivery of the right test at the right time in the right place.
Currently seeking a Board-Certified Cardiologist to participate in pre-authorization and quality improvement solutions for echocardiography, vascular Doppler ultrasound, high-tech diagnostic imaging and cardiac procedures. Physician Advisors determine the medical necessity of requests using clinical appropriateness guidelines and health plan medical policy.
Successful candidates will:
- Determine medical necessity of requests using applicable clinical criteria, which may include AIM Appropriateness Guidelines, client-specific health plan medical policy, well established evidenced based guidelines and CMS Coverage Determinations, as applicable.
- Perform physician-level case review of utilization requests involving echocardiography, vascular Doppler ultrasound, high-tech diagnostic imaging (cardiac and non-cardiac) and cardiac procedures.
- Perform physician-level case review of utilization requests involving cardiac procedures such as percutaneous cardiac intervention and diagnostic cardiac catheterization.
- Conduct peer-to-peer consultations with ordering physicians, physician assistants and advanced practice nurses regarding established guidelines and accepted standards of care as it relates to treatments, procedures, imaging and appropriate sites of service.
- Discuss clinically appropriate alternative treatments, imaging studies and sites of care with ordering providers when consistent with applicable clinical criteria.
- Provide education regarding applicable clinical criteria.
- Perform first level provider appeals of coverage decisions.
- Demonstrate and maintain knowledge of applicable clinical criteria and relevant AIM policies pertaining to utilization review.
- Demonstrate and maintain knowledge of applicable ICD-10, HCPCS and CPT coding guidelines as it relates to cardiology services and procedures.
- Provide support and educate internal clinical and non-clinical staff to foster understanding of the principles associated with appropriate cardiac diagnoses, treatments and management.
- Actively participate in physician team meetings.
- Actively participate in groups that develop, revise and enhance clinical appropriateness guidelines.
- Obtain additional state licensure based upon state regulations and health plan needs.
Current unrestricted medical license(s) as a Doctor of Medicine or Doctor of Osteopathic Medicine in Board Certification in Cardiovascular Disease or Interventional Cardiology by the American Board.
3-5 years of clinical practice experience past fellowship training is desirable
Demonstrated knowledge of current practice standards in cardiology
Strong oral communication and interpersonal skills
Strong analytical skills
Computer literacy with the ability to learn new applications.
Preferred experience with utilization management.
Glendale Medical Physician Job