Responsible for leading physician efforts in supporting the medical management staff ensuring timely and consistent medical decisions to members and providers.
Primary duties may include, but are not limited to:
Provides oversight to physicians and ensures timely completion of clinical case reviews for their board certified specialty.
Ensures consistent use of company medical policies when making medical necessity decisions.
Educates and provides direct medical coverage decision support as needed for team of physician advisors.
Ensures system integrity in alignment with all relevant clinical criteria as related to sources which include client medical policy, compendia alignment, pathway requirements, and CMS guidance.
Interprets and provides feedback on client medical policy.
Provides oversight for clinical integration during implementations, clinical updates, and any system clinical change requirements.
Provides clinical direction for new oncology program expansions.
Participates in AIM Clinical Pathway development and system implementations.
Develops and/or supports workflow and best practices for clinical integration processes.
Qualifications
Requires an MD.
2 years of experience with clinical case reviews for medical necessity preferred.
Board certification in Medical Onocology, Hematology, or Pediatric Hematology and Oncology.