Medical Director/ Physician Reviewer- Otolaryngology (GA, NY, MO, TX) Who We Are: TurningPoint Healthcare Solutions is a leader in advanced clinical and technology-enabled complex condition management.
TurningPoint provides an innovative suite of specialty care management services and technologies that enable health plans and employers to improve the safety, quality, and affordability of healthcare.
Through its platform and specialized team of clinical experts, TurningPoint works collaboratively with providers to deliver optimal care.
TurningPoint offers condition-specific, quality-driven, value-based care management services that optimize care from diagnosis and discovery through recovery.
TurningPoint's comprehensive and integrated suite of services enhances the support individuals need, at the time they need it most.
Since launching in 2015, TurningPoint has provided support to more than 50 million people nationwide across numerous clinical specialties including musculoskeletal, pain management, cardiology, wound care, ear/nose/throat, and sleep.
TurningPoint's model moves beyond denial-based care to holistic condition management that improves outcomes and reduces cost.
TurningPoint is an independent organization, not owned or affiliated with a health plan or provider system.
Position Summary: The primary responsibility of this position is to provide determinations for medical necessity requests.
This role is a 1099 contractor position and is fully remote.
Roles and Responsibilities: Reviewing Otolaryngology cases for medical necessity.Reviewing cases which were not approved by pre-review screening process or by the initial Clinical Reviewer's algorithm.Review of pended cases to obtain all necessary clinical information, and discussion(s) with referring physicians on the appropriateness of the service requested according to the clinical criteria employed by the organization.Conducting a peer-to-peer consultation for all determinations which do not meet the criteria for approval.Rendering an adverse determination, along with justification statements for the adverse determination letter.For appeal determinations, are not the individual who made the original non-certification, nor the subordinate of such an individual; and unless expressly allowed by state or federal law, are in a state or territory of the United States when conducting appeal considerations.Conduct peer-to-peer consultations, adverse determinations, and appeals for drug utilization review, if not prohibited by state laws or the requesting party specifically requests a clinical peer.Acts as a medical resource to the Utilization Management Department staff, as needed.Acts as an active member of the quality committees, if appointed.Follows company policies and procedures.Respects and maintains HIPAA confidentiality guidelines.Other duties as directed.Education, Experience and Licensure: Physician with degrees of MDs or DOs.Current and valid non-restricted license in the USA.
Some states may require state licensure to conduct reviews.Certified by the American Board of Otolaryngology.Practicing in area of specialty for a minimum of five (5) years.Preferred Skills: Excellent interpersonal skills.Responsible and organized individual.Exceptional writing skill.TurningPoint Healthcare Solutions is an Equal Opportunity Employer.
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