SCOPE OF POSITION
Responsible for oversight of physician advisor reviews for private and Medicaid contracts and performs initial and/or reconsideration reviews, as necessary. Develop relationships and promotes mutually beneficial partnerships with employees, clients, key stakeholders, constituents, 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. Support the organization’s mission, vision, and values by exhibiting the following behaviors: Honesty, Excellence Accountability, Respect and Teamwork.

ESSENTIAL JOB FUNCTIONS
1. Responsible for oversight of physician advisor reviews for all private and Medicaid contracts and performs initial and/or reconsideration reviews as necessary:
a. Perform ongoing quality assurance/improvement for physician advisor reviews.
2. Facilitate mission goals across teams at the organizational level.
3. Meet regularly with the Deputy Medical Director and Chief Medical Officer 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, key stakeholders, constituents, legislators, other health care organizations and the community at large.
5. Confer with the Deputy Medical Director, Chief Medical Officer 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. Contribute and edit scientific articles, which will be submitted to medical, epidemiology, or statistical journals.
7. 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.
8. Function as a resource for clinical and non-clinical staff by providing oversight and follow-up for clinical related questions or issues.
9. Support and advise Clinical Review staff.
10. Participate in peer-to-peer clinical review phone conversations, as necessary, to meet contractual obligations.
11. Ensure compliance with AFMC policy, contractual obligations, state and federal laws and regulations.
12. Maintain current knowledge of corporate contracts with emphasis on opportunities for new business.
13. Attend Board Meetings upon CEO request.
14. Adhere to format, content and style guidelines, giving consideration to usability and ensuring accuracy, consistency and quality.
15. Follow AFMC, state and federal protocols regarding data confidentiality/security and HIPAA compliance.
16. Meet regularly with assigned staff to communicate pertinent information, needs and requests to other team members as appropriate.
17. 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 and spelling are required
• Good command of the English language and knowledge of punctuation, grammar, and spelling are required
• Knowledge of regulations and contract requirements pertaining to the assigned area of responsibility
• Ability to lead and participate in multi-disciplinary team projects involving professional personnel from several fields
• Ability to manage and direct the work of outside consultants, outsourced services and other external entities
• Well-developed planning, organizational development and business skills
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• Ability to build and manage partnerships and relationships with a variety of stakeholders required
• Strong detail orientation, organizational and project management skills evidencing an ability to respond to multiple projects simultaneously with appropriate sensitivity and tact including the ability to manage through conflict
• 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, constituents, 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)