Please Note: Associates in this job are paid hourly and are eligible for overtime. To ensure consistent use of this job across the enterprise, please consult with your Human Resources partner prior to using this job (HRBP should work with Compensation). Responsible for supporting the medical management staff ensuring timely and consistent medical decisions to members and providers. Primary duties may include, but are not limited to: Ensures timely completion of clinical case reviews for their board certified specialty. Makes physician to physician calls to gather medical appropriate information in order to make medical necessity determinations for services requested. Makes medical necessity determinations for grievance and appeals appropriate for their specialty. Ensures consistent use of medical policies when making medical necessity decisions. Brings to their supervisors attention, any case review decisions that require Medical Director review or policy interpretation. Requires MD/DO and Board certification approved by one of the following certifying boards is required, where applicable to duties being performed, American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA). Must possess an active unrestricted medical license to practice medicine or a health profession.
Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.