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Description SHIFT: Day JobSCHEDULE: Full-timeYour Talent. Our Vision. At AIM Specialty Health (AIM), a proud member of the Anthem, Inc. family of companies, it’s a powerful combination, and the foundation upon which we’re creating greater care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care. This is an exceptional opportunity to do innovative work that means more to you and those we serve. AIM is currently seeking a Board-Certified Pain Management Physician to participate in pre-authorization and quality improvement solutions for interventional pain management procedures involving the spine. Medical Directors in Clinical Operations determine the medical necessity of requests using clinical appropriateness guidelines and health plan medical policy. Successful candidates will:
Determine medical necessity of requests using applicable clinical criteria, which may include AIM Appropriateness Guidelines, client-specific health plan medical policy, well established evidenced based guidelines and CMS Coverage Determinations, as applicable.
Perform physician-level case review of interventional pain management utilization requests involving the spine such as epidural injections (interlaminar/caudal and transforaminal), medial branch blocks, epidural adhesiolysis, facet joint injection, radioablation, regional sympathetic nerve block, sacroiliac joint injections, spinal cord stimulators and thermal intradiscal procedures following initial clinical review by a therapist reviewer or a nurse reviewer.
Conduct peer-to-peer consultations with ordering physicians, physician assistants and advanced practice nurses regarding established guidelines and accepted standards of care as it relates to interventional pain management treatments, imaging and appropriate sites of service.
Discuss clinically appropriate alternative treatments, imaging studies and sites of care with ordering providers when consistent with applicable clinical criteria.
Provide education regarding applicable clinical criteria.
Perform first level provider appeals of coverage decisions.
Demonstrate and maintain knowledge of applicable clinical criteria and relevant AIM policies pertaining to utilization review.
Demonstrate and maintain knowledge of applicable ICD-10, HCPCS and CPT coding guidelines as it relates to interventional pain management services and procedures.
Provide support and educate internal clinical and non-clinical staff to foster understanding of the principles associated with appropriate musculoskeletal diagnoses, treatments and management.
Actively participate in physician team meetings.
Actively participate in groups that develop, revise and enhance clinical appropriateness guidelines.
Obtain additional state licensure based upon state regulations and health plan needs.
Adhere to all AIM 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 in an appropriate
state.
Board Certification in Pain Management by the American Board of Anesthesiology, or the American Board of Physical Medicine and Rehabilitation
3-5 years of clinical practice experience post fellowship training is preferred.
Demonstrated knowledge of current practice standards in interventional pain management.
Strong oral communication and interpersonal skills.
Intermediate computer skills with the ability to learn new applications.
Strong analytical skills.
Ability to multi-task.
Ability to work both independently and in a team environment.
Ability to work in a dynamic, fast-paced environment.
Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2018 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran.REQNUMBER: PS37964
Vacancy expired!