|Job type||Full Time|
The Medical Peer Reviewer plays a critical role in consulting on medical necessity in the context of utilization management and ensuring adherence to internal Healthfirst and external regulations.
The Medical Peer Reviewer schedule requires 5 hours a day Monday - Friday. The peak hours of the business are 10:00 a.m. -5:00 p.m. and the Medical Peer Reviewer is required to work his/her 5 hours during the core hours to perform the duties and responsibilities of the position. The role has some flexibility within the prescribed time frame. At least one weekend a month is required. If this is the case, the Medical Peer Reviewer will be off in the immediate week after. (Example: If a Medical Peer Reviewer works a total of 10 hours over the weekend, he/she will have day(s) off in the immediate days following.)
• The Medical Peer Reviewer will assess/review requests for authorization, and claims payment, based on medical records and internal Healthfirst information and make informed clinical judgments and recommendations.
• The Medical Peer Reviewer will render determinations in the format and within timeframes to be in compliance with Regulatory and Operational policies.
• The Medical Peer Reviewer schedule requires 5 hours a day, Monday-Friday. The peak hours of the business are 10:00 a.m. -5:00 p.m. and the Medical Peer Reviewer is required to work his/her 5 hours during the core hours to perform the duties and responsibilities of the position. The role has some flexibility within the prescribed time frame.
• The Medical Peer Reviewer will:
• Maintain productivity standards of 8-10 cases per hour (PCA/CDPAS) and nursing home reviews, and 10-12 cases per hour for other types of cases.
• Collaborate with Utilization Management and Care Management and medical departments as needed, reviews and manages cases/caseload from multiple lines of businesses
• Demonstrate the ability to be flexible when case load volume fluxes and when Leadership requests changes in case priorities to support our Members/internal medical departments as needed
• Complete mandatory Company compliance training and training in new systems and software.
• Enter each day's hours worked in Workday, on the same day.
• Perform other duties as assigned
• New York Licensed M.D. or D.O.
• Previous, relevant experience in utilization management and clinical practice
• Knowledge of Medicare, Medicaid, and MLTC plans
• Time management, critical thinking, communication, and problem-solving skills
• Knowledge of UM/QM case philosophies and reporting requirements to state and federal agencies
• Knowledge of member satisfaction/incident management and regulations
• Knowledge of quality improvement methodologies
Compliance & Regulatory Responsibilities:
• Ensures compliance to internal Healthfirst and external regulations.
• Licensed M.D. or D.O. or D.M.D. or D.D.S.
• Annual Compliance and other training as assigned, may include but not limited to hardware, software, and system training upgrades
• Complies with the Healthfirst Conflict of Interest Policy for Professionals
WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.
If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to careers@Healthfirst.org or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.
EEO Law Poster and Supplement
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