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Cardiology Senior Physician Ad...

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Job Summary

Company
Anthem
Location
Westchester, IL
Industries
Other/Not Classified
Job Type
Full Time
Employee
Career Level
Experienced (Non-Manager)
Job Reference Code
4298_130052

Cardiology Senior Physician Advisor - AIM - 130052

About the Job

Description
This position may be located in Westchester or Deerfield, IL; or in Glendale, CA
Your 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 Cardiologist to participate in pre-authorization and quality improvement solutions for echocardiography, vascular Doppler ultrasound, high-tech diagnostic imaging and cardiac procedures. Physician Advisors 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 utilization requests involving echocardiography, vascular Doppler ultrasound, high-tech diagnostic imaging (cardiac and non-cardiac) and cardiac procedures.
  • Perform physician-level case review of utilization requests involving cardiac procedures such as percutaneous cardiac intervention and diagnostic cardiac catheterization.
  • 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 treatments, procedures, 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 cardiology services and procedures.
  • Provide support and educate internal clinical and non-clinical staff to foster understanding of the principles associated with appropriate cardiac 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.

About AIM Specialty Health

AIM Specialty Health is a specialty benefit management company that helps promote appropriate, safe and affordable healthcare services. For more than 25 years, we have been an innovator, leader and partner to payers and other risk bearing organizations that manage health outcomes and costs. With a suite of solutions, we provide value through clinical appropriateness review, provider collaboration and member engagement. Our solutions focus on today's most complex and costly tests and treatments in radiology, cardiology, oncology, specialty drugs, sleep medicine, and other emerging clinical areas. We design and administer our solutions on behalf of 50 health plans, which support a diverse client base and over 42 million members, and engage with more than 330,000 providers throughout the US to help improve the quality of care and reduce costs.

We maintain offices in Chicago, Deerfield, Schaumburg and Westchester, IL as well as Glendale, CA. This position can be located in our Westchester, Deerfield or Glendale contact centers.
AIM's services include:
  • Prospective clinical review of outpatient advanced imaging procedures such as CT, MRI, Nuclear Cardiology and PET Scans
  • Clinical review for cardiology and specialty pharmacology products and services.
  • Oncology Management programs leveraging AIM's proven specialty benefit platform to drive consistent and effective cancer care through services review along with management of close to 70 oncologic drugs and radiation therapy.
  • Specialty Drugs programs to provide review for over 142 specialty drugs offering providers an automated drug review process through our provider friendly web portal.
  • Sleep Management, designed to align the diagnosis and treatment of sleep apnea against clinical guidelines, enhance member access to high value providers and ensure treatment compliance for the dispensing of supplies.
Our programs combine clinical excellence, innovative technology and a commitment to customer service, ensuring the company's on-going leadership in the rapidly evolving healthcare environment.
AIM is certified by the National Committee for Quality Assurance (NCQA) and has received Full Accreditation for Health Utilization Management from the Utilization Review Accreditation Commission (URAC.)
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 Cardiovascular Disease or Interventional Cardiology by the American Board of Internal Medicine.
  • 3-5 years of clinical practice experience past fellowship training is desirable.
  • Demonstrated knowledge of current practice standards in cardiology.
  • Strong oral communication and interpersonal skills.
  • Computer literacy 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.
  • Preferred experience with utilization management, especially with CMS guidelines.

Anthem, Inc. is ranked as one of America's Most Admired Companies among health insurers by Fortune magazine and is a 2016 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at antheminc.com/careers. EOE. M/F/Disability/Veteran.

 

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