Medical Physician Job in Watertown, Massachusetts : MA 02472
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Part Time Behavioral Health Physician Reviewer, Medical Affairs
Part Time Behavioral Health Physician Reviewer, Medical Affairs Job Description
The Utilization Review Physician will primarily perform utilization management functions for all Tufts Health Plan products, including but not limited to Commercial, Medicare and Medicaid. These functions will include prospective, concurrent and retrospective utilization review. The Utilization Review Physician will work closely with staff from all partner UM and Medical Management Departments on utilization review activities. In addition, s/he may provide input on provider claims payment disputes, perform retrospective claims audits of medical records, review of potential quality of care issues, and review of TMP cases involving bridging. For these functions, the Utilization Review physician will work closely with other departments including Claims Operations, Actuarial, and Clinical Quality Improvement.
KEY RESPONSIBILITIES/ESSENTIAL FUNCTIONS* (in order of importance)
* Performs clinical review of prospective, concurrent, and retrospective coverage requests for in-patient and out-patient services requiring prior authorization and medical review
* May be required to communicate with providers, provider groups, facilities, and others as necessary to resolve clinical issues and concerns
* Supports the provider inquiry line
* Performs clinical review of expedited and standard appeals
* Participates in inter-rater reliability exercises
Case Management Support
* Provides physician support and leadership for case management rounds and care planning activities for all products
* Provides physician expertise and input for provider appeals
* May participate in relevant committees as requested
* Will participate in staff meetings and other meetings as requested
EDUCATION: (Minimum education required)
* Utilization Reviewer will be a Board Certified MD who has had at least five years of clinical experience.
* S/he is required to have a current unrestricted Massachusetts license as a medical or osteopathic doctor.
EXPERIENCE: (Years of experience)
* Minimum five years of clinical experience.
* S/he will have had significant utilization management experience or other relevant experience, either at another health plan or at a local provider unit, medical group, or health care facility
SKILL REQUIREMENTS: (Include interpersonal skills)
* Tufts Health Plan Policies and Procedures
* Performs utilization management activities in accordance with accreditation standards and regulatory guidelines described in Tufts Health Plan UM Policy and Procedure Manual
* Render medical necessity coverage determinations in accordance with Tufts Health Plan Medical Necessity Guidelines and the member's benefit document
* Render provide appeal decisions following Tufts Health Plan claims payment policies
* S/he will have an understanding of principles of utilization management and quality assurance.
* S/he will have the skills to communicate with and educate Tufts Health Plan participating physicians in a non-confrontational manner. S/he will be an effective "team player", with excellent interpersonal, cross-departmental and leadership skills.
WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS: (include special requirements, e.g., lifting, travel, overtime)
* Tufts Health Plan is a fast paced professional environment requiring a high level of initiative and robust decision-making skills. Effective use of a personal computer is important. While this position is considered as part - time, given the dynamic nature of the work environment and professional nature of the role, there may be occasions where some additional work in the course of a given week may be necessary. In addition, there may be occasional early morning or evening meetings.
CONFIDENTIAL DATA: All information (written, verbal, electronic, etc.) that an employee encounters while working at Tufts Health Plan is considered confidential. Exposed to and required to deal with highly confidential and sensitive material and must adhere to corporate compliance policy, department guidelines/policies and all applicable laws and regulations at all times.
Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled
Watertown Medical Physician Job