/This position may be located in Westchester or Deerfield, IL; or in Glendale, CA/
Your Talent. Our Vision. AtAIM Specialty Health(AIM), a proud member of the Anthem, Inc. family of companies, it's a powerful combination, and the foundation upon which we're creating greater care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care. This is an exceptional opportunity to do innovative work that means more to you and those we serve.
AIM is currently seeking a Board-Certified Orthopedic or Physical Medicine and Rehabilitation physician to participate in pre-authorization and quality improvement solutions for high-tech diagnostic imaging and musculoskeletal management . Physician Reviewers determine the medical necessity of outpatient requests using clinical appropriateness guidelines and health plan medical policy.
Successful candidates will:
Perform physician-level case review, following initial nurse review, of high-tech diagnostic imaging and other musculoskeletal management solutions.
Determine medical necessity of requests using AIM Clinical Appropriateness Guidelines and client-specific health plan medical policy
Conduct peer-to-peer consultations with ordering physicians, physician assistants, and advanced practice nurses to provide education regarding established guidelines and accepted standards of care regarding studies and site of service.
Suggest clinically appropriate alternative treatments, studies and sites of care to ordering providers when applicable
Provide support and educate clinical and non-clinical staff to foster understanding of the principles associated with appropriate use of covered modalities.
Actively participate in physician team meetings.
Demonstrate and maintain knowledge of relevant policies and regulations pertaining to sleep management, and imaging modalities.
Actively participate in groups that develop, revise and enhance clinical appropriateness guidelines
Perform first level provider appeals of coverage decisions.
Obtain additional state licensure based upon state regulations and health plan needs
Adhere to all AIM Specialty Health protocols, policies, and procedures
About AIM Specialty Health
AIM Specialty Health is a specialty benefit management company that helps promote appropriate, safe and affordable healthcare services. For more than 25 years, we have been an innovator, leader and partner to payers and other risk bearing organizations that manage health outcomes and costs. With a suite of solutions, we provide value through clinical appropriateness review, provider collaboration and member engagement. Our solutions focus on today's most complex and costly tests and treatments in radiology, cardiology, oncology, specialty drugs, sleep medicine, and other emerging clinical areas. We design and administer our solutions on behalf of 50 health plans, which support a diverse client base and over 42 million members, and engage with more than 330,000 providers throughout the US to help improve the quality of care and reduce costs.
We maintain offices in Chicago, Deerfield, Schaumburg and Westchester, IL as well as Glendale, CA. This position can be located in our Westchester, Deerfield or Glendale contact centers.
AIM's services include:
Prospective clinical review of outpatient advanced imaging procedures such as CT, MRI, Nuclear Cardiology and PET Scans
Oncology Management programs leveraging AIM's proven specialty benefit platform to drive consistent and effective cancer care through services review along with management of close to 70 oncologic drugs.
Clinical review for cardiology and specialty pharmacology products and services.
Specialty Drugs programs to provide review for over 142 specialty drugs offering providers an automated drug review process through our provider friendly web portal.
Sleep Management, designed to align the diagnosis and treatment of sleep apnea against clinical guidelines, enhance member access to high value providers and ensure treatment compliance for the dispensing of supplies.
Our programs combine clinical excellence, innovative technology and a commitment to customer service, ensuring the company's on-going leadership in the rapidly evolving healthcare environment.
AIM is certified by the National Committee for Quality Assurance (NCQA) and has received Full Accreditation for Health Utilization Management from the Utilization Review Accreditation Commission (URAC.)
Qualified Candidates will have:
Current unrestricted medical license(s) as a Doctor of Medicine or Doctor of Osteopathic Medicine in an appropriate state.
Board Certification in Orthopaedic Surgery by American Board of Orthopaedic Surgery; or in Physical Medicine and Rehabilitation by the American Board of Physical Medicine and Rehabilitation.
Demonstrated knowledge of current practice standards in specialty
Strong oral communication and interpersonal skills
Computer literacy with the ability to learn new applications
Strong analytical skills
Ability to multi-task
Ability to work both independently and in a team environment
Ability to work in a dynamic, fast-paced environment
Anthem, Inc. is ranked as one of America's Most Admired Companies among health insurers by Fortune magazine and is a 2015 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at antheminc.com/careers. EOE. M/F/Disability/Veteran.
Title: Orthopedics/PMR Senior Physician Case Reviewer AIM 116658
Other Locations: CA-Glendale, IL-Deerfield
Requisition ID: 116658
A little about us:
We have shared values and a similar mission.