Physician Reviewer

Overview

Oversees the utilization of medical care and treatment of VNS MSO members and provides direction and guidance to the staff to assure appropriate and expedient decision‑making with attention to quality of care. Consults and cooperates with internal and external partners. Works under general direction.

• Referral bonus opportunities
• Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays
• Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life and Disability
• Employer‑matched retirement saving funds
• Personal and financial wellness programs
• Pre‑tax flexible spending accounts (FSAs) for healthcare and dependent care
• Generous tuition reimbursement for qualifying degrees
• Opportunities for professional growth and career advancement
• Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities

• Provides medical determinations for purposes of Utilization Management (UM), initial and internal appeals decisions. This includes review of clinical information provided against evidence‑based guidelines, ensure plan compliance with regulatory requirements, focus on improving quality of care, and support departments of VNS MSO that request medical review services.
• Reviews internal staff or external provider rationales related to coverage decisions.
• Reviews relevant medical records and clinical information on file in the context of performing clinical reviews. (e.g.: inpatient hospital records, outpatient professional notes, Letters of Medical Necessity (LOMN), assessment reports, etc.)
• Utilizes appropriate, evidence‑based guidelines for reviews and organizational determination such as. (e.g.: Medicare NCDs, LCDs, Medicaid guidelines, MCG guidelines, VNS Health policies, etc.)
• Provides clinical case summary and determination rationale and member letter verbiage as appropriate.
• Ensures decisions deadlines are met and adhere by business goals and ensure compliance.
• Completes and documents peer‑to‑peer consultation according to policy through completion of any finalized decision.
• Participates in interdisciplinary rounds.
• Reviews Quality of Care (QOC) concerns, care records and QOC summary. Assist with case summary, case level assignment and recommended next steps.
• Participates in special projects and performs other duties as assigned.

Licenses and

Certifications:

Licensed to practice medicine in state of residence required Licensed to practice medicine in New York State preferred Specialty Board Certified or Eligible required Board Certification in Internal or Family Medicine preferred Certification in Geriatric Care preferred

Education: Medical Degree required

Work Experience: Minimum five years of experience in clinical medicine, including three years in managed care, and application of evidence based medical necessity criteria and CMS guidance required Prior experience in geriatric medicine preferred Prior experience in Utilization Management (UM) and/or a Medical Services Organization preferred Demonstrated strong knowledge of Medicare and Medicaid regulatory and reporting requirements required Strong communication and influential skills required Exceptional critical thinking and decision‑making skills preferred

USD $ - USD $ /Yr.

VNS Health is one of the nation’s largest nonprofit home and community‑based health care organizations. Innovating in health care for more than 130 years, our commitment to health and well‑being is what drives us — we help people live, age and heal where they feel most comfortable, in their own homes, connected to their family and community. On any given day, more than 10,000 VNS Health team members deliver compassionate care, unparalleled expertise and 24/7 solutions and resources to the more than 43,000 “neighbors” who look to us for care.

Powered and informed by data analytics that are unmatched in the home and community‑health industry, VNS Health offers a full range of health care services, solutions and health plans designed to simplify the health care experience and meet the diverse and complex needs of the communities and people we serve in New York and beyond.