Orthopedics Physician

What You Will Be Doing: Serve as the Physician match reviewer in Hip/Knee/Shoulder Surgery cases, that do not initially meet the applicable medical necessity guidelines, as well as other imaging requests when providers, clients, or state laws require specialty reviews to be completed by the subject matter expert. Discusses determinations (peer to peer phone calls) with requesting physicians or ordering providers, when available, within the regulatory timeframe of the request and provides clinical rationale for standard and expedited appeals. Utilizes medical/clinical review guidelines and parameters to assure consistency in the MD review process to reflect appropriate utilization and compliance with SBU s policies/procedures, as well as Utilization Review Accreditation Commission (URAC) and National Committee for Quality Assurance (NCQA) guidelines. Aids and acts as a resource to Initial Clinical Reviewers. Ensures documentation of all communications with medical office staff and/or MD provider is recorded in a timely and accurate manner. May assist the Senior Medical Director in research activities/questions related to the Utilization Management process, interpretation, guidelines and/or system support. Participates in on-going training per inter-rater reliability process.