Job Details

SCOPE OF POSITION
Perform initial and reconsideration reviews for private and Medicaid contracts. Develop relationships and promote mutually beneficial partnerships with employees, clients, other healthcare organizations, and the community at large. Support the organization’s mission, vision, and values by exhibiting the following behaviors: Honesty, Excellence, Accountability, Respect and Teamwork. This position is work from home. 

ESSENTIAL JOB FUNCTIONS

1. Perform initial and reconsideration reviews for private and Medicaid contracts.
2. Facilitate mission goals across teams at the organizational level. 
3. Meet regularly with the Medical Director of Clinical Services to stay informed, to offer direction and support for inter-departmental projects, and to confer on organizational goals, objectives, and policies.
4. Develop relationships and promote mutually beneficial partnerships with clients, other health care organizations, and the community at large.
5. Confer with the Medical Director and management to identify and develop new opportunities for expanding the business. Monitor current contracts and clients to identify and establish “new business” goals and revenue growth opportunities. 
6. Review pertinent medical record and represent the details of the rationale provided by external physician reviewers and willingness to provide testimony based on that review in an open court proceeding (i.e., fair hearing). Fair hearings could require an in-person appearance if requested.
7. Function as a resource for clinical and non-clinical staff by providing oversight and follow-up for clinically related questions or issues. 
8. Support and advise Clinical Services staff.
9. Participate in peer-to-peer clinical review phone conversations, as necessary, to meet contractual obligations.
10. Ensure compliance with AFMC policy, contractual obligations, and state and federal laws and regulations.
11. Maintain current knowledge of corporate contracts with emphasis on opportunities for new business. 
12. Attend Board Meetings upon CEO request. 
13. Adhere to format, content, and style guidelines, ensuring accuracy, consistency, and quality.
14. Follow AFMC, state, and federal protocols regarding data confidentiality/security and HIPAA compliance.
15. Additional duties as assigned.

KNOWLEDGE, SKILLS, AND ABILITIES

• Intermediate skill level with MS Office (Word, Excel, Outlook, and PowerPoint)
• Type 40 wpm
• Exceptional skills in business English, spelling, punctuation, and grammar.
• Knowledge of regulations and contract requirements pertaining to the assigned area of responsibility
• Ability to lead and participate in multi-disciplinary team projects 
• Well-developed planning, organizational development, and business skills
• Ability to negotiate and reach mutually agreeable solutions
• Ability to maintain confidentiality
• Coaching skills
• Creativity
• Customer service
• Ability to delegate as required
• Ability to meet deadlines
• Flexibility
• Ability to work collaboratively and independently to achieve stated goals
• Initiative
• Ability to relate professionally and positively with staff, business partners, customers, recipients, and the public
• Leadership skills
• Knowledge of ICD-9/ICD-10 Coding
• Knowledge of HIT/EHR
• Medical terminology
• Ability to prioritize
• Problem solving skills
• Professionalism
• Strong public speaking skills
• Ability to travel, including overnight travel.
• Time management skills
   

Physical and sensory requirements (with or without the aid of mechanical devices)
Mobility, reaching, bending, lifting, grasping, ability to read and write, ability to communicate with personnel, ability to remain calm under stress. Must be capable of performing the essential job functions of this job, with or without reasonable accommodations. 

EDUCATION
Required: Current unrestricted clinical license in the state of Arkansas as a Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO). Must be Board certified.
Desirable: Master’s degree in public health, healthcare administration, or business administration

EXPERIENCE
Required: Five (5) years full-time equivalent direct patient care experience and direct patient care experience within the previous three (3) years. Must be a practicing physician involved in direct patient care. 
Preferred: Two years of experience in medical review, quality improvement, or health care management. Experience in providing professional testimony in a legal setting. Experience and knowledge of Medicaid and other major managed health care programs. 

INTERNET REQUIREMENTS:
Reliable, high-speed wireless internet service (Wi-Fi)