Assistant Medical Director

Description:
? Provide benefit coverage determinations based on medical necessity and contract language
? Support clinical review activities including pre-service, post-service, concurrent facility-based care
? Act as the final decision maker for coverage decisions
? Use clinical expertise to support claims review decisions
? Support peer-to-peer discussion process with external physicians
? Consult with nursing and other clinical staff to assess care options
? Participate in the development and annual review of company medical review criteria
? Leverage clinical knowledge and expertise to support ongoing education for clinicians
? Provide professional advisement for consultation requests
? Participate in Inter-Rater Review process for consistency in clinical decision making
? Understand and abide by federal, state, and accreditation regulations
? Complete all professional continuing education requirements

Requirements: ? Physicians license with an MD or DO degree ? Unrestricted Washington state licensure or administrative license or ability to obtain within 90 days ? Five (5) years of clinical experience ? Current board certification from the American Board of Medical Specialties, or the American Osteopathic Association or other recognized Association acceptable to Premera ? Previous experience performing medical necessity and clinical reviews in a health plan setting (Preferred) ? Prior use of clinical criteria sets and clinical pathways, such as MCG (Milliman Care Guidelines), Interqual? or others (Preferred) ? Familiarity with CPT, ICD, HCPC code sets and RBRVS pricing concepts (Preferred)

Benefits:
? Medical, vision and dental coverage
? Life and disability insurance
? Retirement programs (401K employer match and pension plan)
? Wellness incentives, onsite services, a discount program and more
? Tuition assistance for undergraduate and graduate degrees
? Generous Paid Time Off to reenergize
? Free parking

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