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Expertise Forge Connections Pvt. Ltd.

Job title: Physician Reviewer Schedule: M-F(8-5) Contract: 2+ Years Location: Remote (but must have Texas Medical Licensure) Pay rate: $110Hour on W2Description:<ul><li>Evaluates clinical service requests made by an organization's members and providers.</li><li>Uses clinical judgment in conjunction with organization's criteria to adjudicate these requests.</li><li>May also provide clinical leadership in other areas of the organization. Identifies opportunities to manage members' clinical situations with a view toward creative problem solving and anticipation of possible future clinical problems for the member.</li><li>Participates in the process to evaluate clinical service requests.</li><li>Practices anticipatory case management for members whose cases come for review, in partnership with case managers.</li><li>Participates in the development of Physician Review Units' policies and procedures.</li><li>Actively participates in all unit continuous quality improvement activities.</li><li>Other duties as assigned by the Medical Director.</li><li>Board Certified (ABMS) M.D. or D.O, unrestricted and active license to practice medicine requested and 5 years clinical experience to include inpatient experience, or any combination of education/experience that would provide an equivalent background.</li><li>Must have understanding of managed care and</li></ul>Job Types: Full-time, ContractPay: $100.00 - $110.00 per hourBenefits:<ul><li>Dental insurance</li><li>Referral program</li><li>Vision insurance</li></ul>Work Location: In person

Physician Reviewer

Job title: Physician Reviewer Schedule: M-F(8-5) Contract: 6+ Months Location: Remote (but must have Board Certification) Pay rate: $130Hour on W2Job Summary:<ul><li>The ideal candidate will leverage their extensive clinical experience to enable delivery of CSBs market-leading strategies, improving the lives of the individuals we serve.</li><li>The CSB Medical Director will work closely with CSBs National Medical Director and CSB leadership to identify opportunities to manage and improve clinical reviews and processes, deploy new innovations, and collaboratively engage clinical expertise across the Enterprise.</li><li>Key Job Functions:</li><li>Provides clinical expertise and support for all departments and divisions related to the clients Medicare Supplement (Medigap) and Individual Supplemental Health and Life (SHL) Insurance products, including but not limited to, Underwriting, Legal, Marketing, Operations, Product, and Claims.</li><li>Has clinical responsibility for helping to ensure the strategic and tactical delivery of project work for our clients Supplemental Health products in forty-nine states and the District of Columbia (DC).</li><li>Provides clinical resources and education to a multi-disciplinary team of nonclinical staff for CSB, responsible for supporting Medigap underwriters in all aspects of the underwriting process, assists SHL Claims Representatives with complex claims consults, appeals and reviews, rescissions, as well as fraud and abuse cases.</li><li>Oversees the Supplemental Benefits Clinical Team (SBCT), which is a multifunctional team that includes Medical Directors, pharmacist(s), data analyst(s), and other ad hoc members as needed from across the Enterprise.</li><li>Works closely with the actuarial team for the clinical integrity of various undertakings, involving underwriting, pricing, claims automation, and cost analysis.</li><li>Responsible for clinical input to the development of new innovative tactics and methodologies to improve cost containment for Medigap and SHL products, such as Preventive Care, vendor solutions, and other medical management initiatives.</li></ul>Minimum Qualifications Education &amp; Experience:<ul><li>The CSB Medical Director will be a Board-certified physician with current unrestricted medical license with a minimum of 10-years of clinical practice experience. Candidates must be able to obtain medical license and other state licenses as needed.</li></ul>Competencies &amp; Skills<ul><li>Experience in Medigap, Supplemental Health Insurance, and Medical Underwriting is preferred.</li><li>MBA or equivalent experience preferred.</li><li>Proven ability to assess complex issues, recommend change and resolve issues.</li><li>Strong skills in the following areas: teamwork, communication, negotiation, conflict management, problem solving, effective decision making, and cooperative relations with diverse internal and external stakeholders.</li><li>Demonstrated ability to effectively educate clinical staff and non-clinical staff.</li><li>Strong computer skills and technical independence. Data science background a plus.</li><li>Strong strategic thinking, analytical, and decision-making capabilities.</li><li>Accomplished at developing and delivering professional presentations to various audiences, including senior management.</li><li>Able to work independently and under pressure.</li><li>Strong interpersonal skills and collaboration mindset, able to develop effective relationships with internal/external stakeholders.</li></ul>Job Types: Full-time, ContractPay: $120.00 - $130.00 per hourBenefits:<ul><li>Dental insurance</li><li>Referral program</li><li>Vision insurance</li></ul>Work Location: In person

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Expertise Forge Connections Pvt. Ltd.

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Physician Reviewer

Physician Reviewer