This position may be located in Westchester or Deerfield, IL; or in Glendale, CA
Successful candidates will:
Perform physician-level case review, following initial nurse review, of sleep studies and high-tech diagnostic imaging. Determine medical necessity of requests using 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 alternative studies and sites of care to ordering providers when appropriateProvide 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 Specialty Health protocols, policies, and procedures.
Qualifications
Qualified Candidates will have:
Current unrestricted medical license(s) as a Doctor of Medicine or Doctor of Osteopathic Medicine
Current Board Certification in a Sleep Medicine subspecialty under the American Board of Medical Specialties.Demonstrated knowledge of current practice standards in specialty
Strong oral communication and interpersonal skills
Computer literacy with the ability to learn new applications
Ability to multi-task
Ability to work both independently and in a team environment
Ability to work in a dynamic, fast-paced environment
Successful candidates will:
Perform physician-level case review, following initial nurse review, of sleep studies and high-tech diagnostic imaging. Determine medical necessity of requests using 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 alternative studies and sites of care to ordering providers when appropriateProvide 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 Specialty Health protocols, policies, and procedures.
Qualifications
Qualified Candidates will have:
Current unrestricted medical license(s) as a Doctor of Medicine or Doctor of Osteopathic Medicine
Current Board Certification in a Sleep Medicine subspecialty under the American Board of Medical Specialties.Demonstrated knowledge of current practice standards in specialty
Strong oral communication and interpersonal skills
Computer literacy with the ability to learn new applications
Ability to multi-task
Ability to work both independently and in a team environment
Ability to work in a dynamic, fast-paced environment