Clinical Reviewer, Nurse Practitioner/Physician Assistant – Vascular Surgery
Employment Information
Report this job
Job expired or something wrong with this job?
Job Description
Nurse Practitioner/Physician Assistant providing clinical support in Vascular Surgery for Evolent, enhancing patient care within the healthcare system. Responsible for clinical liaison duties and quality improvement functions.
Responsibilities:
- Responsible for acting as a clinical liaison to providers, clients, and patients as directed by the office of the Chief Medical Officer.
- Responsible for clinical conversations with providers and their office staff regarding medical necessity decisions.
- Responsible for maintaining and operating the Guideline Directed Medical Therapy including communicating with offices recommendations regarding medical therapy.
- Responsible for communicating need for additional clinical information to ordering providers.
- Responsibility for prepping cases which cannot be approved and which the provider will not modify or withdraw for P2P discussions with one of the Vascular Surgeons or Cardiologists.
- Responsible for coordinating with UM staff to ensure timely and accurate communication of clinical decisions.
- Responsible for completion of UM projects and participation in site visit reviews.
- Respect and maintain HIPAA confidentiality guidelines.
- Responsible for maintaining availability to clinical and non-clinical administrative staff during performance of initial and second level screening
- Acts as an interdepartmental liaison between all New Century Health offices, departments, and committees.
- Serve as subject matter expert and participate in meetings as assigned with practices and/or payers.
- Will work with the Director of UM to ensure client satisfaction.
- Perform all peer clinical review activities while located in a state or territory of the United States.
- Acts with honor and integrity, serving as a role model for the company.
Requirements:
- Master of Science in Nursing or Doctor of Nursing Practice (DNP) degree from a recognized degree program OR a master’s degree from a program accredited by the ARC-PA
- Minimum of five (5) years’ experience in the practice of Vascular Surgery (preferred) or primary care; knowledge of regulatory requirements with at least two years of experience in a regulatory role (preferred)
- Current, unrestricted state PA or RN/NP license in medicine or required specialty
- Of a PA, obtaining a passing score on a national certifying exam
- Obtaining and maintaining required licenses in the states where NCH has business
- Strong clinical, management, communication, and organizational skills
- Demonstrated leadership skills
- Analytic skills
- Energetic and curious with a passion for quality and value in health care
- Required to pass skills proficiency test
Benefits:
- comprehensive benefits (including health insurance benefits)
Similar Jobs
Medical Reviewer, LPN
Medical Reviewer LPN conducting pre-authorization reviews for HCSC. Focusing on utilization review and quality of care compliance.
Physician Clinical Reviewer – Allergy/Immunology
Physician Clinical Reviewer evaluating clinical cases while ensuring medical necessity guidelines compliance at Prime Therapeutics. Collaborates with physicians to resolve determinations and assists with appeals.
Physician Clinical Reviewer – Pediatric Oncologist
Clinical Reviewer for pediatric oncology at Prime Therapeutics, reviewing service requests and helping in clinical decision making. Engaging with healthcare professionals to ensure adherence to medical guidelines as part of utilization management.
Physician Clinical Reviewer – Pediatric Neurology
Physician Clinical Reviewer in pediatric neurology conducting medical reviews and collaborating with health professionals. Ensuring compliance with guidelines and regulations through documentation and communication.
Physician Clinical Reviewer – Urology
Clinical Reviewer for utilization management focusing on Urology. Engaging with physicians and patients to ensure adherence to clinical guidelines and rationales.
Physician Clinical Reviewer – Endocrinology
Physician Clinical Reviewer responsible for medical review of service requests in utilization management. Collaborating with physicians and health plan members to ensure compliance with guidelines.
Physician Clinical Reviewer – Pediatric Gastroenterology
Clinical Reviewer at Prime Therapeutics evaluating pediatric gastroenterology service requests and overseeing clinical determinations in a remote setting.
Physician Clinical Reviewer – Nephrology
Physician Clinical Reviewer reviewing medical necessity requests for Prime Therapeutics. Collaborating with healthcare professionals to ensure compliance with treatment guidelines and policies.
Physician Clinical Reviewer – Orthopedics
Physician Clinical Reviewer responsible for reviewing clinical determinations and liaising with healthcare providers. Engages in quality assurance and compliance with medical guidelines and regulations in a remote capacity.
Physician Clinical Reviewer – Cardiology
Physician Clinical Reviewer providing medical reviews for service requests at Prime Therapeutics. Engaging with physicians and participating in appeals, focusing on patient care and compliance.
Physician Clinical Reviewer – Oncologist
Clinical Reviewer-Oncologist providing timely medical review of service requests. Interacting with physicians and staff while ensuring compliance with medical necessity guidelines.
Physician Clinical Reviewer – Ophthalmology
Key member reviewing service requests that do not meet medical necessity guidelines. Interacting with healthcare professionals to ensure compliance and proper documentation in ophthalmology.
Physician Clinical Reviewer – Dermatology
Physician Clinical Reviewer specializing in Dermatology at Prime Therapeutics. Responsible for reviewing clinical service requests and interacting with healthcare providers in the remote capacity.
Physician Clinical Reviewer – Family Practice
Physician Clinical Reviewer providing timely medical review of service requests at Prime Therapeutics. Engaging with physicians and regulatory compliance in a remote role.
Physician Clinical Reviewer – Gastroenterology
Clinical Reviewer for Prime Therapeutics handling medical review of service requests. Collaborates with physicians and ensures compliance with policies and guidelines.
Physician Clinical Reviewer – Pediatric Rheumatology
Clinical Reviewer responsible for medical review of pediatric rheumatology service requests. Supporting utilization management processes and collaboration with healthcare providers at Prime Therapeutics.
Physician Clinical Reviewer – Rheumatology
Physician Clinical Reviewer reviewing service requests for medical necessity at Prime Therapeutics. Engaging with physicians and health plan members to ensure adherence to clinical guidelines.
Clinical Reviewer, Nurse – Medical Oncology
Clinical Reviewer, Nurse responsible for performing precertification and prior approvals for Oncology patients. Ensuring the provision of quality care through effective utilization reviews and collaboration with healthcare professionals.
Medical Reviewer, USRN – Wound Care
Medical Reviewer joining healthcare client to ensure accuracy of patient claims and documentation. Contributing to patient care outcomes from a remote setting with an emphasis on wound care expertise.
Clinical Reviewer, Behavioral Health
Behavioral Health UM Clinician conducting benefit coverage reviews and managing utilization for Point32Health. Collaborating with leadership to improve service and ensure compliance with clinical requirements.