• Medical Consultant

    Job Locations US-RI-Smithfield
    Req No.
    2018-8639
    Department
    Medical Directors Office
    Type
    Regular Full-Time
    Category
    Medical/Health
  • Overview

    The role of the Medical Consultant is to provide clinical support to the Director of Pharmacy, Associate Medical Directors and Chief Medical Officer in providing clinical input to Medical Review, Expense Management and Medical Management activities.

    Responsibilities

    • Provide clinical expertise to the Medical Review process by 
      • performing review of medical and pharmacy requests for non-benefit or restricted benefit services
      • engaging providers in discussions of medical necessity
      • notifying members and providers of decisions
      • guiding development and application of Clinical Benefit Guidelines
      • and meeting all regulatory expectations of review processes
    • Serve as clinical resource to Medical Management for 
      • development and maintenance of Clinical Practice Guidelines
      • development of Clinical Medical Policies
      • clinical and disease management programs and
      • research and consultation as requested by nurse case managers
    • Provide clinical expertise to the Quality Assurance process by performing review and recommendation for member and provider complaints, and participate as a member of the Quality Assurance Committee in decision for actionable follow-up to complaints
    • Assist in preparation for regulatory and accreditation reviews
    • Represent Neighborhood in meetings or other forums with practitioners, regulators, purchasers, etc.
    • Comply with Neighborhood policies and procedures on Confidentiality
    • Other duties as assigned
    • Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood’s Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies, and procedures as it applies to individual job duties, the department, and  the Company. This position must exercise due diligence to prevent, detect, and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents.

    Qualifications

    Required:

    • Physician, unrestricted license in the State of Rhode Island; no restrictions in any state
    • Board certified in a primary care or other relevant specialty
    • Excellent analytical and communication skills

    Preferred:

    • Previous clinical practice and/or Health Plan experience
    • Ongoing part-time clinical practice preferable
    • Board certified in a primary care or other relevant specialty

    Neighborhood is an Affirmative Action and Equal Opportunity Employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, genetic information, age, disability, veteran status or any other legally protected basis.

     

    Neighborhood is committed to ensuring individuals with disabilities and/or those who have special needs participate in the workforce and are afforded equal opportunity to apply for jobs. If you would like to contact us regarding the accessibility of our Website or need assistance completing the application process, please contact us at recruiting@nhpri.org

     

    Neighborhood is an EOE M/F/D/V and an E-Verify Employer

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