Returning Candidate?

Physician Reviewer/Medical Director

Physician Reviewer/Medical Director

Job ID 
2017-4036
Job Locations 
US-CT-Hartford
Category 
Clinical/Utililization Management

More information about this job

Overview

The CareCentrix Post-Acute Care program is a comprehensive offering that manages financial risk for the costs of care for 90-days after a patient’s discharge from the hospital. The program identifies the recommended site-of-care for the patient, manages length of stay (LOS) if a Skilled Nursing Facility (SNF) is appropriate, and aims to reduce hospital readmissions. Our program also coordinates all of the services required for a patient to transition to their home faster and safer, by using home health, durable medical equipment and home infusion providers; all of whom are supported by our readmission reduction team.  

 

Leading the Path Home with HomeBridge℠

 

This position provides clinical oversight of the Post-Acute Care (PAC) program for CCX, performing the full range of PAC medical necessity reviews utilizing Interqual as well as Client’s clinical criteria for Skilled Nursing Facility (SNF), Long Term Acute Hospital (LTACH)/Inpatient Rehabilitation Facility (IRF) as well as Home Health Service, DME and Home Infusion,

The PAC Medical Director provides consultative services to CareCentrix PAC staff as needed.

Responsibilities

  • Consults with licensed and non-licensed associates on clinical issues related to authorization requests and clinical guidelines clinical criteria.
  • Conducts medical necessity review on cases that may not meet criteria, and issues adverse determinations as needed
  • Accepts and conducts case discussions as well as peer-to-peer consultations when requested by an ordering healthcare professional after an adverse determination has been issued, adhering to required timelines for this activity
  • Participates in the CCX Care Coordination, Utilization Management and Quality Improvement committees, and other Performance improvement activities as requested.
  • Provides input into CCX clinical guidelines, criteria and other decision support tools, including evaluations and recommendations on new and emerging technologies, and industry standard treatment protocols relevant to CCX business.
  • Interfaces with key positions within CCX including the Chief Medical Officer and executive team members, and serves as a clinical resource for communications with clients and business partners.
  • Utilizes clinical integrity in all determinations.
  • Collaborates with Health Plan clinical leadership as requested. Participates in special projects and performs other duties as assigned.
  • Participates in case reviews with the CCX clinical team and provides educational support as needed.
  • Has periodic consultation with practitioners in the field

 

Qualifications

Must be an MD or DO with an active and unencumbered medical license in Connecticut.  Additional licenses in other states may be required, depending on the CareCentrix client payer account rules, which may require multiple state licenses to be held concurrently.  Minimum of 5 years’ experience in an area of relevant clinical practice, and prefer at least 3 years’ experience with supporting utilization management reviews, managed care programs or care delivery networks. Should have expertise in the Post-Acute Care  field, including current knowledge on best practices, as well as a general knowledge of requirements of regulatory and accreditation standards for payers and health care providers. Must be able to travel to and participate in meetings at hospitals, rehabilitation facilities, clinics, and health plans, and other locations as needed

 

CareCentrix maintains a drug-free workplace in accordance with Florida’s Drug Free Workplace Law.