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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