Minimum Experience Required
The successful candidate will be an M.D. or D.O. with a current, active, U.S. state medical license and board certified in a clinical specialty recognized by the American Board of Medical Specialties (ABMS), with recent practice experience in direct patient care (within the past 18 months).
Knowledge of applicable state and federal laws, URAC and NCQA standards a plus, and familiarity with automated processes and computer applications and systems is required.
- Provides timely expert medical review for requests to evaluate the medical necessity of services that do not meet utilization review criteria while located in a state or territory of the United States.
- Reviews appeals for denied services related to current relevant medical experience or knowledge in accordance with appeal policies, if so delegated.
- Provides timely peer-to-peer discussions with referring physicians to clarify clinical information and to explain review outcome decisions.
- Documents all actions related to clinical review sessions and attests to appeal review qualifications as required.
- Maintains files of all reviews as required by law and Health Plans to retrieve reportable data.
- Maintains necessary credentials and immediately informs eviCore of any adverse actions relating to medical licenses and/or board certifications.
- Supports the annual review of utilization review criteria.
- Supports and communicates eviCore policy and procedures to the provider community.
- Participates in strategic planning for and evaluation of the Care Management process/unit.
- Assists with staff educational training and in-service programs and serves as a clinical resource for eviCore staff.