Reports to the Senior VP of Clinical Operations with accountably to Chief Financial Officer and Chief Medical Officer.
Work with UM licensed staff, Regional Medical Officers and Extensivists to develop and implement methods to optimize use of Institutional and Outpatient services for all patients.
Complete clinical reviews for medical necessity, treatment appropriateness and compliance.
Second level reviews in compliance with Medicare/CMS: NCD, LCD and Milliman guidelines for Inpatient, Outpatient, Skilled Facilities Level of Care and Pharmacy.
Provide appropriate level of care classifications as well as continued stay reviews in compliance with CMS and Milliman guidelines.
Act as a liaison between the medical staff, utilization review and third-party payers to effectively promote the appropriate levels of medical care.

3-5 years of experience in hospital-wide or skilled nursing facility position involving clinical care, quality management, utilization and case management, or medical staff governance required.
Completion of medical school and specialty residency (preferably in internal medicine).
Board Certification.
Current, non-restricted licensure as required for clinical practice in the State or US territory in which medical decisions are being made.
Excellent communication skills.
Great attention to detail as well as taking pride in being a good team member and communicate effectively with medical staff.

Alignment Health

Open Positions (1)