Primary Responsibilities:

• Conduct coverage reviews based on individual member plan benefits and national and proprietary coverage review policies, render coverage determinations • Document clinical review findings, actions, and outcomes in accordance with policies, and regulatory and accreditation requirements • Engage with requesting providers as needed in peer-to-peer discussions • Be knowledgeable in interpreting existing benefit language and policies in the process of clinical coverage reviews • Participate in daily clinical rounds as requested • Communicate and collaborate with network and non-network providers in pursuit of accurate and timely benefit determinations for plan participants while educating providers on benefit plans and medical policy • Communicate and collaborate with other internal partners • Call and holiday coverage rotation

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• M.D or D.O • Active unrestricted license to practice medicine • Board certification in Internal Medicine or Family Medicine; to include genetics experience • Ability to obtain additional licenses as needed • Sound understanding of Evidence Based Medicine (EBM) • Solid PC skills, specifically using MS Word, Outlook, and Excel • Ability to participate in rotational holiday and call coverage

Preferred Qualifications:

• 5+ years of clinical practice experience after completing residency training • Experience in utilization and clinical coverage review • Proven excellent oral, written, and interpersonal communication skills, facilitation skills • Proven data analysis and interpretation aptitude • Proven innovative problem-solving skills • Proven excellent presentation skills for both clinical and non-clinical audiences