Provide remote medical management support for members with spine-related needs, using orthopedic spine or neurosurgery expertise to review cases, predeterminations, and claim determinations. This role combines utilization review, quality assurance, and clinical guidance to support care across the continuum. It also serves as a liaison to providers and facilities, using multiple computer-based applications to support consistent medical management decisions.
Key Responsibilities
- Conduct utilization review and quality assurance activities for spine-related cases.
- Provide clinical expertise for predetermination reviews and claim determinations.
- Coordinate case management support and responses for members and providers.
- Act as a clinical and business liaison to network providers and facilities.
- Participate in clinical team activities that support medical management programs.
- Use computer-based applications to document and evaluate medical, coding, and reimbursement information.
- Support medical management staff with timely and consistent case responses.
Required
- M.D. or D.O. degree.
- Board certification in Orthopedic Spine or Neurosurgery.
- Active, current state medical license in good standing.
- At least 2 years of experience in health care delivery, such as clinical practice or the health care industry.
- Post-graduate direct patient care experience in the relevant specialty.
Preferred
- Previous health insurance experience.
Benefits & Perks
- Remote work from home anywhere in the U.S.
- Full-time position.
- Starting base salary of $300K.
- Eligibility for bonus, commission, or short-term incentive program.
- Equity award target.
- Comprehensive benefits package including medical, dental, and vision coverage.
- Paid time off and retirement savings options.
- Wellness programs and other colleague resources.