The primary purpose of this position is to render medical necessity determinations up to first level of practitioner clinical appeal. Work independently, receiving minimal guidance and supervision. A more detailed account of individual job expectations will be clarified through individualized Job Accountabilities documents.
· Performance of Peer-Review – Clinical Quality Evaluation
· Medical necessity review up to first level practitioner appeal
· Conduct timely, accurate, and (inter- and intra-) consistent reviews in order to verify and approve medically/clinically necessary and appropriate care and services for our health plan members.
· Medical record review consistent with the medical record scoring criteria.
· Credentialing file review consistent with the Credentialing Program and criteria
· Effectively communicate rationale for clinical decision making to peers using evidence/outcomes-based principles and professional experience.
· Document all telephonic communications, via phone log/CHIP system, detailing all pertinent facts and resolutions to issues discussed with practitioners.
· Follow appropriate protocols to track and report practitioners, through our Clinical Quality Investigation Team (CQIT) processes, whose practice patterns do not meet professionally recognized standards of practice and generate Clinical Quality Investigations when appropriate.
· Conduct outreach calls as assigned.
· Participate in Clinical Quality Administration and Clinical Quality Evaluation workgroups
· Promote a productive Team environment
· Participate in clinical article review activities as assigned.
· Interdepartmental Support to Medical Necessity Administration department as necessary for performance of assigned tasks
· Performs other duties and responsibilities as assigned.
Knowledge / Skills / Ability:
Problem Solving / Judgment:
· Critical evaluation of submitted clinical documentation in order to make medical necessity determinations with the scope of accountabilities
· Ability to apply evidence-based criteria and approved guidelines to specific medical necessity review scenarios and describe clinical rationale consistently and effectively
· Ability to independently resolve problems or issues related to clinical determinations using good judgment or to escalate problems or issues to supervisor(s) as appropriate
· Ability to exercise strict confidentiality in all matters.
General Knowledge / Skills:
· Use of computer systems in business application including, but not limited to, 10-key, Outlook, MS-WORD, IHIS and CHIP.
· Core competencies as indicated on most current performance review form.
· Ability to communicate evidence-based clinical criteria, approved clinical guidelines, and the rationale for clinical decisions effectively and in a professional manner.
· Ability and willingness to serve as a peer-clinician resource to assist practitioners to interact more effectively and efficiently within ASH programs and systems.
· Ability to control emotions and interact respectfully while seeking channels of communication that will improve a situation.
· Ability to actively and objectively listen to feedback
· Ability to see, to speak, and to hear other personnel and/or objects.
· Ability to communicate both in oral and written form.
· Ability to travel within the facility.
· Capable of using a telephone and computer keyboard.
· Ability to lift up to 10 lbs.
· Primarily Sedentary.
ASH Companies - 11 months ago