Physician Reviewer

Cincinnati Children's

1d • Remote

About The Position

JOB RESPONSIBILITIES Medical Review - Performs medical review activities pertaining to delegated pediatric services including medical review of complex, controversial, or experimental medical services. Quality - Assists Medical Director in improving quality and cost-effectiveness of care and service for members and provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, institutional, and accreditation requirements. Utilization - Identifies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components. Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care and interfaces with physicians and other providers in order to facilitate implementation of recommendations. Participates in robust interrater reliability audit process. Education - Assists in the development and implementation of physician education with respect to clinical issues and policies. Medical Leadership - Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities. Serves as an expert physician resource and reviewer.

Requirements

• M.D. or D.O.
• Board certification AND maintenance of certification
• Must have current, unrestricted license to practice medicine in the state of Ohio
• Previous experience in clinical medical practice
• Familiarity with the Ohio Department of Medicaid (ODM) provider agreement requirements and state regulations, including Ohio Revised Code (ORC) and Ohio Administration Code (OAC)
• Experience with managed care utilization management process and have the ability to communicate with physicians regarding clinical care decision guidelines
• Current, unrestricted MD or DO Licensure in state(s) of practice

Responsibilities

• Performs medical review activities pertaining to delegated pediatric services including medical review of complex, controversial, or experimental medical services.
• Assists Medical Director in improving quality and cost-effectiveness of care and service for members and provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, institutional, and accreditation requirements.
• Identifies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components.
• Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care and interfaces with physicians and other providers in order to facilitate implementation of recommendations.
• Participates in robust interrater reliability audit process.
• Assists in the development and implementation of physician education with respect to clinical issues and policies.
• Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities.
• Serves as an expert physician resource and reviewer.

What This Job Offers

• Job Type: Part-time
• Career Level: Mid Level
• Education Level: Ph.D. or professional degree