Provides clinical program leadership and develops, implements and approves policies within recognized area of responsibility.
Develop and maintain medical policy. Establish rationale for approving inquires and appeals.
Assists with clinical research, writing documents, and documenting decisions.
Provide utilization management for prior authorization procedures. Review cases and make decisions based on medical policy.
Provide clinical support to various areas of the organization. Process requests for clarification, interpretation, or questions about policy or benefits. Review potential impacts of clinical matters.
Serves as clinical resource and subject matter expert to both clinical and non-clinical staff.
Perform clinical reviews and conduct peer to peers.
Participate in JUMP committee meetings.
"Qualifications"
Doctorate from an accredited school of medicine (M.D.) or osteopathy (D.O) required.
Seven (7) years clinical practice experience.
Current unrestricted state of Michigan Doctor of Medicine (M.D.) or doctor of osteopathy (D.O.) license.
Board certified or board eligible and working towards certification in a specialty approved by the American Board of Medical Specialists or the American Board of Osteopathy.
Proven leadership, problem solving, and the ability to manage multiple priorities.
Strong teaching and communication skills.
Results oriented and the ability to take ownership for initiatives and collaborate with cross-functional teams to achieve department and corporate goals.
Demonstrated skill with Microsoft Office Suite and web-based programs.
Understanding of health plan functions related to utilization, care, and quality management.
Other related skills and/or abilities may be required to perform this job.
Department Summary / Preferences:
Specialty Care Knowledge is preferred.
Medical Policy Experience is a plus.
All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.
