Medical Peer Reviewer

Job description

Job Profile Summary A vital role of the CMO Administration team, the Medical Peer Reviewer plays a critical role in consulting on medical necessity in the context of utilization management and ensuring adherence to internal Healthfirst and external regulations. Duties/Responsibilities: ·The Medical Peer Reviewer will assess/review requests for authorization, and claims payment, based on medical records and internal Healthfirst information and make informed clinical judgments and recommendations. ·The Medical Peer Reviewer will render determinations in the format and within timeframes to follow Regulatory and Operational policies. · The Medical Peer Reviewer will: ·Maintain productivity standards. · Collaborate with Utilization Management and Care Management and medical departments as needed, reviews and manages cases/caseload from multiple lines of businesses ·Demonstrate the ability to be flexible when case load volume fluxes and when Leadership requests changes in case priorities to support our members/internal medical departments as needed ·Complete mandatory Company compliance training and training in new systems and software. ·Enter each day’s hours worked in Workday, on the s...