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Contribute approved content for Marketing Communications utilization in brochures, tradeshows, advertising and digital marketing efforts utilizing internal document control and review process.
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Primary Responsibilities: Oversight of health plan utilization management and appeals and grievance processes – The Associate Medical Director is the accountable owner for all Medicaid utilization management processes as well as appeals and grievances.
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The candidate for this position will be expected to identify and lead the development, implementation, monitoring and process improvement of new and current programs, including the application and refinement of the pharmacy practice model and oversee the quality and outcomes programs required to maintain Utilization Review Accreditation Commission (URAC) and Accreditation Commission for Health Care (ACHC) specialty pharmacy accreditation requirements.
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Provides timely expert medical review for requests to evaluate the medical necessity of services that do not meet utilization review criteria while located in a state or territory of the United States.
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Provides timely peer-to-peer discussions with referring physicians to clarify clinical information and to explain review outcome decisions. The successful candidate will be an M.D. or D.O. with a current, active, U.S. state medical license and board certified in Maternal - Fetal Medicine, recognized by the American Board of Medical Specialties (ABMS), with recent practice experience in direct patient care (within the past 18 months.
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Knowledge of applicable state and federal laws, URAC and NCQA standards a plus, and familiarity with automated processes and computer applications and systems is required. Must have a minimum of 5 years clinical experience, beyond residency/fellowship.
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Essential Functions: Under close supervision of the RBM, achieve all territory management, call activity goals and performance objectives for geographical assignment(s) including but not limited to call activity, sample and resource utilization, target reach and frequency, and sales performance.
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Complete pre and post call analysis which positively impacts customer rly review and analyze all available sales data and utilize developmental budget funds Under close supervision of the RBM, adhere to all compliance policies and guidelines.
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Communicates with the Utilization Review Department and Business Department regarding authorization and payment. Provides utilization reviews to insurance companies, providing appropriate clinical information to obtain initial authorization and continuing stay authorization, as necessary.
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Must have a minimum of 5 years clinical experience, beyond residency/fellowship Knowledge of applicable state and federal laws, URAC and NCQA standards a plus, and familiarity with automated processes and computer applications and systems is requiredNo nights, no weekends, not call.
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Participates in strategic planning for and evaluation of the Care ManagementThe successful candidate will be an M.D. or D.O. with a current, active, U.S. state medical license and board certified in Oncology Radiation, recognized by the American Board of Medical Specialties (ABMS), with recent practice experience in direct patient care (within the past 18 months.
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Must be proficient with Microsoft Excel, including the utilization of pivot tables and vlookup functions. Review and audit expense reports in Certify prior to uploading them into the financial software, Microsoft Great Plains.
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Participates in strategic planning for and evaluation of the Care Management. Health, dental, vision, and life benefits with employer funded HSA. The successful candidate will be an M.D. or D.O. with a current, active, U.S. state medical license and board certified in Neurology, recognized by the American Board of Medical Specialties (ABMS), with recent practice experience in direct patient care (within the past 18 months.
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Flexible scheduling and work/life balance with remote and work from home opportunities. Reviews appeals for denied services related to current relevant medical experience or knowledge in accordance with appeal policies, if so delegated.
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Meet with teams in conjunction with Team or Company Leadership to review monthly a) large claims, b) abnormal utilization results, c) managed care and ongoing case management opportunities.
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review utilization jobs Title: associate
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