Physician Reviewer, part-time (myNEXUS)

at Anthem, Inc in Wilmington, Delaware, United States

Job Description


SHIFT: Day Job

SCHEDULE: Part-time

Your Talent. Our Vision. At myNEXUS, a proud member of the Anthem, Inc. family of companies, it’s a powerful combination. It’s the foundation upon which we’re creating greater access to care for our members, greater value for our customers and greater health for our communities. Join us and together we will drive the future of health care. myNEXUS is a technology-driven, care and benefit management service that enables individuals to live healthier lives in their homes. Our proven clinical model connects individuals to intelligent care delivering independence at lower costs. To maximize health delivery, we consistently leverage our: Innovative Technologies, Advanced Clinical Expertise, and Proprietary Network Engagement Platform. We are continuously pioneering ways to optimize health resources for our clients and their customers. Through our proprietary network management and engagement programs, we realize enhancements in quality, outcomes, and care effectiveness. Job Summary: The Physician Case Reviewer at myNEXUS will be a key member of the Operations team, engaged in performing Level III/peer reviews. The position reports to the Sr. Medical Director of Operations. The Physician Case Reviewer will communicate with the operations UM nursing and therapy staff regarding the review of patient documentation to determine certification or non-certification of home-based benefits. Responsibilities of this position also include will also communication with ordering physicians and practitioners to facilitate the delivery of medically reasonable and necessary care. Duties/Responsibilities:

+ Performs Level III utilization review of home-based benefits to determine if the requested service can be certified or is considered a non-certification of services.

+ Accurately documents clinical justification for determinations and follows Utilization Management Policies when completing reviews.

+ Documents clinical justification and instructs Operations Coordinators to proceed with notifying the member, the Home Health Care Agency, DME or Infusion Therapy Provider and the ordering physician in writing of the non-certification of services.

+ Responds to peer-to-peer call requests from ordering physicians in a timely fashion. Contributes medical input to the Clinical Solutions Team.

+ When indicated, initiates proactive outreach discussions with ordering physicians to obtain or share clinical information.

+ Facilitates timely review of both urgent and routine service requests.

+ Makes outreach calls to request additional clinical information when such information is required to accurately complete reviews.

+ When requested, discusses clinical aspects of service requests with clinical review staff. Participates in care conference discussions with review staff.

+ Identifies themselves by name, title, and company name on all telephone calls. Provides, upon request, information on specific UM requirements and processes.

+ Consults with Sr. Medical Director or Sr. Medical Director’s designee, if there are questions regarding a case meeting clinical criteria.

+ Collaborates with members of the Quality and Appeals teams when requested.

+ Maintains up-to-date knowledge of Medicare and Medicaid home health medical necessity and justification requirements.

+ Maintains and respects confidentiality of members’ personal health information.

+ Consults with practitioners (nurses, therapists, and social workers) in the field as needed.

+ Makes suggestions to Sr. Medical Director of around clinical protocols, processes or communications.

+ Stays abreast of emerging models in health care delivery and technology.

+ Builds and takes advantage of cross functional collaborative relationships to achieve shared company goals.

+ Encourages collaboration with both internal and external healthcare team members.

+ Supports strategic goals related to the quality improvement, management programs and accreditation standards.

+ Assists as needed with business development activities.

+ Works with internal team members to pursue and maintain state medical licensure in specific states as requested by management

+ Participates in performance improvement activities for department and CQI activities.

+ Consults other departments as appropriate to collaborate in member care and performance improvement activities.

+ Recognizes member safety issues and advocates for care in an environment that optimizes member safety.

+ Uses clinical judgment in authorizations that fall outside of guideline parameters.

+ Maintains a good working relationship both within the department and with other departments.

+ Accepts additional assignments willingly.

Professional Responsibilities:

+ Completes annual education requirements.

+ Maintains patient confidentiality at all times.

+ Reports to work on time and as scheduled, completes work within designated time.

+ Follows all company policies related to time records.

+ Completes in-services in a timely fashion.

+ Attends annual review and department in-services, as scheduled.

+ Attends staff meetings as scheduled and reads all staff meeting minutes and other written documents as requested.

+ Represents the organization in a positive and professional manner.

+ Actively participates in performance improvement and continuous quality improvement (CQI) activities.

+ Complies with all organizational policies regarding ethical business practices.

+ Communicates and demonstrates the mission, ethics and goals of the facility, as well as the focus statement of the department.

Position Requirements: Experience Required:

+ Doctor of Medicine degree (M.D. or D.O.) required

+ Board Certification by the American Board of Medicine Specialties in his/her respective specialty, preferred

+ Active, unrestricted state medical license

+ A minimum of 5 years professional post-residency experience in direct patient care

+ Knowledge of managed healthcare systems, medical quality assurance, quality improvement and risk management.

Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For® , is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions. REQNUMBER: PS49986 To view full details and how to apply, please login or create a Job Seeker account
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Job Posting: JC182948839

Posted On: May 06, 2021

Updated On: Sep 16, 2021