Physician Advisor, part-time Job in Quincy, Massachusetts Us
Who we are
Harvard Pilgrim is a not-for-profit health plan and a full-service benefits company serving members in Massachusetts, New Hampshire, Maine and beyond. We make health care work better. We recognize diversity's impact and importance for our workforce, customers and providers, and through our contributions to the communities we serve. It's part of the way we do business.
What we value
Harvard Pilgrim believes that greatness is built from the inside out. It's created by individuals who share common goals, and who support and rely on one another to achieve them. Our core values guide us in how we treat, respond to and interact with our customers, business partners and one another.
Who we hire
We hire the best and brightest-talented individuals who value innovation, creativity and communication in the workplace. Harvard Pilgrim believes that by attracting, retaining and engaging diversetalent, we gain a sustained competitive advantage for continued growth.
Our employees bring Harvard Pilgrim's mission, values and brand to life in an inclusive and supportive environment where they are respected and valued for their contributions. Being part of the Harvard Pilgrim team means that you excel at what you do. You're dedicated to your work and continually look for new ways to serve your customers better.
What we offer
We do our best to support our employees in making the most of their lives both inside and outside of work. At Harvard Pilgrim, we know that a talented, engaged and inclusive workforce is our greatest strength. We have an excellent benefit package and are "T" accessible.Some of our benefits include:
* A comprehensive work and life benefits program, including medical and dental benefits, time away from work, retirement, financial protection and on-site fitness centers.
* Opportunities to learn and grow, build relationships, share your opinions and do what you do best every day.
* Ways to serve and give back to the communities where you live, work and play - through grants, fundraising and volunteering.
JOB SUMMARY:
Reporting directly to the Medical Director for Medical Management and Quality, the Physician Adviser provides clinical support for Preauthorization/Utilization Management, Member Appeals, Provider Appeals, Care Management and other departments within HPHC.
Essential Functions:
- Supports UM department staff and nurse case managers on concurrent review and pre-authorization referrals and ensures that members receive clinical services consistent with their benefits, regulatory requirements and established clinical criteria.
- Provides clinical support for Member and Provider appeals and assists Medical Director for Medical Management and Quality in seeking opportunities to improve appeals determinations and documentation.
- Supports clinical concerns, pharmacy, care and disease management and specialty case management, as needed.
- Participates as UM representative on the Member Appeals and Member Appeals Reconsideration Committees and other inter-departmental committees, as needed.
- Provides clinical support to Payment Policy regarding claims payment and coding issues.
- Performs Peer-to-Peer discussions, as applicable, and educates physicians and others on current policy, case management and medical management issues.
- Assists the Medical Director for Medical Management and Quality in the identification and implementation of opportunities for improving the physician review process (including research and documentation of UM determinations).
- Assists in new technology assessment and clinical policy review as required and has facility in researching the evidence-based literature, including use of MEDLINE, UpToDate and/or comparable databases.
- Provides clinical support to the Utilization Management and Clinical Policy Committee regarding medical policy.
- Complies with all the regulatory requirements of DOL, DOI, DPH, CMS, NCQA, URAC, and others as required by statue, regulation and certification for HPHC.
- Works with the Medical Director for Medical Management and Quality in the development and implementation of clinical initiatives, such as utilization, quality and disease management efforts.
- Provides leadership and clinical mentoring for the UM and care management professionals and works collaboratively with both clinical and non-clinical staff.
- Performs other duties as needed and assigned by the Medical Director for Medical Management and Quality relevant to UM, Appeals and the clinical policy process.
Working Conditions:
Normal office conditions. Hours Monday 8:30-5:00pm. Some travel between HPHC offices but based in Quincy, MA.
Part-time = 1 day/week.
- MD or DO with current Massachusetts or other current state Medical License to practice without restriction
- 5 10 years clinical experience
- Board certification in an ABMS-approved medical specialty
- Managed care/administrative experience in a network environment; prior experience in utilization management.
- Strong interpersonal skills; team player who works well with both clinical and non-clinical staff ; good analytical and teaching skills; detail oriented; excellent written and verbal communication skills; ability to establish immediate rapport/credibility within the medical community.
- Must be comfortable and competent in basic computer skills, Microsoft Word, Intranet and Internet connection, and demonstrate documentation skills (typing).
If you'd like to join Harvard Pilgrim, we'd like to hear from you!
Please visit www.harvardpilgrim.org to set up a job agent.
Harvard Pilgrim supports individuals in reaching their full potential by supporting equal employment opportunities and an environment that actively values diversity and inclusion. Harvard Pilgrim complies with all applicable laws concerning hiring and employment practices and is firmly committed to fostering and maintaining a workplace free from discrimination. We pledge to hire, train, and promote our employees without regard to race, religion, gender, gender identity, age, national origin, sexual orientation, disability, veteran status or any other category protected by applicable law.
