Email Opening Apply Now Title Physician Subject Matter Expert  Category Healthcare Quality   Description Reporting to the Provider Resources, Inc (PRI) Chief Medical Officer and the Program Integrity Medical Director, the Physician Subject Matter Expert will provide leadership and support of PRI contracts and staff of PRI as assigned. The Physician Subject Matter Expert will provide counsel, advice and strategic direction incorporating a clinical point of view. S/he will perform tasks as assigned, which may include comprehensive medical record and claim reviews for medical necessity, interpretation of code set application, adherence to regulation, terms of coverage, utilization, practice guidelines, quality improvement guidance, insights on new clinical interventions including policy, systems infrastructure, and clinical insights, and any other client directive. Responsibilities Understand and represent PRIs mission, vision, and values to all internal and external customers Engage clients in appropriate communication that manages client expectations and builds a collaborative relationship with the client. Interact with government and private sector clients, partners, and PRI staff in a professional and accountable manner, and as a representative of PRI. Contribute to business development efforts for new sales and marketing to promote the business, including responses to requests for quotes, sources sought, proposals, and/or presentations as requested Perform clinical reviews for medical necessity, interpretation of code set application, adherence to regulation, terms of coverage and any other client directive as requested. Maintain compliance with all regulation changes as they impact medical and utilization review practices. Analyze patient records and participate in interdisciplinary collaboration with PRI staff and all recognized teaming partners and/or subcontractors. Document all review information into the appropriate Medical Review form, report and/or system. Communicate these report results to the appropriate supervisor. Utilize electronic health information imaging Utilize Internet and Intranet resources for policy verification Make clinical judgments based on clinical experience when applicable Engage and develop educational programs for staff and clients as required to ensure quality outcomes Provide clinical, policy, and health systems insights related to the healthcare system Perform other duties as requested   Position Requirements Current, non-restricted licensure or certification as required for clinical practice in a state of the United States (for applicable internal and/or external review contracts) Five (5) years full-time equivalent experience providing direct clinical care to patients (for applicable internal and/or external review contracts) Experience providing direct clinical care to patients within the past three (3) years (for external review contracts) If an M.D. or D.O., has board certification by a medical specialty board approved by the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA) (for applicable internal and/or external review contracts) If a D.P.M., has board certification by the American Board of Podiatric Surgery (ABPS) or the American Board of Podiatric Orthopedics and Primary Podiatric Medicine (ABPOPPM) (for applicable internal and/or external review contracts) Must accept only cases for review where s/he holds an unrestricted license and is in the same or similar specialty as typically manages the medical condition, procedures, or treatment under review Experience in utilization management, quality management and clinical policy and protocol development One year or more of federal and local policy applications in relation to insurance procedures for medical necessity and benefit coverage preferred Must have no adverse actions pending or taken against him/her by any State or Federal licensing board or program Knowledgeable of ICD-9-CM, CPT-4 and HCPCS coding Knowledge of Microsoft office suite such as Outlook, Access, Excel and Word Knowledge of Interqual screening criteria and MCG (formerly Milliman Care Guidelines) Knowledge of policy development and application of evidenced based medicine Must have no conflict of interest (COI) as defined in 1154(b)(1) of the Social Security Act (SSA) Ability to obtain and maintain U.S. Government Security Clearance Preference will be given to individuals who: Reside in, or are willing to relocate to, a recognized HUBZone area.(Go to www.sba.gov/hubzone for more information) Bilingual, specifically English – Spanish (able to read and write) PRI is an equal employment opportunity employer.  All qualified applicants including Disability/Vets or other qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, disability status, protected veteran status or any other characteristic protected by law.     Degree   Certification   Specialty/Subspecialty   Position Physician Subject Matter Expert   Location Provider Resources Inc - Nationwide   EOE Statement PRI is an equal employment opportunity employer. All qualified applicants including Disability/Vets or other qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, disability status, protected veteran status or any other characteristic protected by law.   This position is currently accepting applications. Apply Now WE ALSO RECOMMEND Other Jobs Within Same Category -- None found -- Other Jobs Within 60 Miles -- None found --

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