This position is responsible for providing utilization review and management services, and general clinical support to Tivity Health Physical Medicine Utilization Management Program. Specific UR/UM services include pre and post service medical necessity reviews, reconsiderations and appeals.
Essential Job Responsibilities:
1. Perform pre-service clinical peer reviews as assigned.
2. Perform post-service clinical peer reviews of out of network claims as assigned.
3. Perform peer to peer discussions, reconsideration and appeal reviews as assigned.
4. Participation in group reviewer meetings as scheduled.
5. Participate in the Inter-Rater Reliability Assessment process.
6. Maintain compliance with security, confidentiality and patient privacy requirements.
7. Understand and comply with State and federal regulatory requirements.
8. Complete Tivity Health annual compliance training for security, confidentiality, privacy, code of conduct and URAC regulations.
9. Work independently but in partnership with multidisciplinary team to assure the members receive the highest quality of care, application of benefits and established criteria for decision making.
10. Complete special projects and other duties, as needed
To apply, please send CV to firstname.lastname@example.org.
Education Doctor of Medicine or Osteopathic Medicine (MD or DO degree); must successfully complete a residency program and be board- certified.
Experience A minimum of 5 years’ experience in clinical practice; experience in physical medicine and rehabilitation specialty is preferred; experience in utilization review and quality assurance is preferred.
Knowledge / Skills: Ability to read, analyze and interpret documents, such as company policies and procedures, and medical records.
Ability to apply clinical criteria and medical necessity guidelines, and interpret various instructions furnished in written, oral, or electronic form.
Proficiency using a personal computer and ability to use typical business software (e.g., MS Office Suite) and specific UR/UM applications as required by Tivity Health.
Ability to communicate clearly and concisely, write routine correspondence and effectively communicate over the phone with clinical professionals.
Licenses / Certifications: Must have a current, active, and unrestricted physician license to practice medicine within a state or territory of the United States (pursuit of additional state licenses may be required based on business needs) is required.
Tivity Health: For three decades, Tivity Health has been dedicated to improving the human condition. Each year, we learn more and do more for the millions of individuals who count on us to make a difference in their health and well-being. Tivity Health is a global provider of solutions that help employers, health plans and government agencies enhance business performance and reduce healthcare costs. Our mission is to create a healthier world, one person at a time.
Tivity Health Work Environment: At Tivity Health, as we continue to make the world a healthier place, we have also created an environment where people choose to do their best work. Our unique culture thrives on mission-driven individuals who exude a high sense of energy and passion in everything that they do. Collaboration and teamwork are an essential part of everyday life for Colleagues who trust and depend on one another to achieve the highest degree of collective success. We are an organization that strives to recruit the best and the brightest individuals who take pride in the statement "I work for Tivity Health."
About Tivity Health
Tivity Health is a leading provider of fitness and health improvement programs, with strong capabilities in developing and managing network solutions. Through our existing three networks (SilverSneakers® - the nation’s leading fitness program for older adults, Prime® - membership access to the nation’s largest network of fitness centers, and WholeHealth Living – specialty medical network development and benefits management), Tivity Health is focused on targeted population health for those 50 and over.
Tivity Health is an equal employment opportunity employer and is committed to a proactive program of diversity development. Tivity Health will continue to recruit, hire, train, and promote into all job levels without regard to race, religion, gender, marital status, familial status, national origin, age, mental or physical disability, sexual orientation, gender identity, source of income, or veteran status.