Director, Medical Reviewer

Member Engagement Columbus, Ohio


Description

The Director, Medical Reviewer makes determinations on healthcare and treatment requests and provides clinical expertise within the organization.

% of Time Spent

Essential Tasks/Duties/Responsibilities

60%

Render determinations on requests for healthcare services and/or treatment when one of the following occur:

There are no established criteria related to the request

There is a lack of information and the nurse is not able to assess against the established criteria

The request is complex or controversial in nature

The request does not meet criteria for approval when reviewed against established criteria

Provide determination on requested reviews to Quantum Health clinical staff within the established time frames

 

15%

Available for peer to peer discussion regarding determination if applicable

 

Provide determination on appeals for cases where you did not make the initial determination

 

Document all determinations and submit to Quantum Health clinical staff

 

15%

Review and discuss complex cases with Quantum Health clinical staff

 

Assist in the development of clinical criteria when criteria does not exist

10%

Provide clinical expertise in support of medical management programs through participation in clinical team activities.  Provide clinical expertise to Sales and Client Engagement.

 

 

Skills and Qualifications

  • Current, unrestricted license to practice medicine
  • Board certification in primary specialty recommended
  • Five years of progressively related work experience preferred
  • Physician clinical review experience preferred
  • Strong written and verbal communication skills
  • Team oriented and a collaborative mindset
  • Knowledge of health care delivery system
  • Knowledge of utilization management and InterQual criteria