Healthfirst
Medical Peer Reviewer
The Medical Peer Reviewer assesses requests for authorization and claims payment by reviewing medical records and internal information to make informed clinical judgments. The role involves collaborating with Utilization Management, Care Management, and medical departments, maintaining productivity standards, and ensuring compliance with internal and external regulations.
Key Responsibilities
- • Assess/review requests for authorization, and claims payment, based on medical records and internal Healthfirst information and make informed clinical judgments and recommendations.
- • Render determinations in the format and within timeframes to follow Regulatory and Operational policies.
- • 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 same day.
- • Perform other duties as assigned.
- • Responsibilities may be adjusted based on changing needs of the organization.
Required
- • Licensed M.D. or D.O. or D.M.D. or D.D.S.
- • Board Certified in a specialty recognized by the American Board of Medical Specialties
- • Annual Compliance and other training as assigned, may include but not limited to hardware, software, and system training upgrades
- • Annual Inter-Rater Reliability (IRR) Testing
- • Complies with the Healthfirst Conflict of Interest Policy for Professionals
Preferred
- • Board Certified in Internal Medicine, Family Practice, OBGYN, Emergency Medicine
- • Previous, relevant experience in utilization management and clinical practice
- • Knowledge of Medicare, Medicaid, and MLTC plans
- • Time management, critical thinking, communication, and problem-solving skills
- • Knowledge of UM/QM case philosophies and reporting requirements to state and federal agencies
- • Knowledge of member satisfaction/incident management and regulations
- • Knowledge of quality improvement methodologies
Benefits & Perks
- • Medical, dental and vision coverage
- • Incentive and recognition programs
- • Life insurance
- • 401k contributions
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
Licensed M.D. or D.O. or D.M.D. or D.D.S.
Board Certified in a specialty recognized by the American Board of Medical Specialties
Preferred Qualifications
In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.
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 same day.
- Perform other duties as assigned
- Responsibilities may be adjusted based on changing needs of the organization.
- The Medical reviewer requires 25 hours a week of coverage. The configuration of the 25 hours may change with the business needs, with a minimum of 3 days a week, 2 days at 8 hours and one day at 9 hours. Maximum of 5 days a week of coverage
- The Medical Reviewer will take 8 hours off during the week after being primary coverage for a weekend, usually the following Friday.
- Each Medical Reviewer will cover one legal holiday /year and will be compensated Holiday pay and straight hours worked
- The Medical Reviewer is eligible for Paid Time Off (PTO) and is required to plan and schedule time off with their direct supervisor following the Company policy.
- Each Medical Reviewer is required to be primary coverage one weekend a month
- Each Medical Reviewer is required to be available as back up, if needed, one weekend a month
- Dental Reviewers have a fixed schedule
Licensed M.D. or D.O. or D.M.D. or D.D.S.
Board Certified in a specialty recognized by the American Board of Medical Specialties
Preferred Qualifications
- Board Certified in Internal Medicine , Family Practice, OBGYN, Emergency Medicine
- Previous, relevant experience in utilization management and clinical practice
- Knowledge of Medicare, Medicaid, and MLTC plans
- Time management, critical thinking, communication, and problem-solving skills
- Knowledge of UM/QM case philosophies and reporting requirements to state and federal agencies
- Knowledge of member satisfaction/incident management and regulations
- Knowledge of quality improvement methodologies
- Licensed M.D. or D.O. or D.M.D. or D.D.S.
- Annual Compliance and other training as assigned, may include but not limited to hardware, software, and system training upgrades
- Annual Inter-Rater Reliability (IRR) Testing
- Complies with the Healthfirst Conflict of Interest Policy for Professionals
- Greater New York City Area (NY, NJ, CT residents): $122,907 - $188,020
In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.
- The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.
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