Job Description

Medical Director/ Physician Reviewer- Pain ManagementWho We Are: TurningPoint Healthcare Solutions is disrupting the traditional approach to specialty care management through innovative technology and world-class clinical expertise. Founded in 2014, TurningPoint has built a team of 400+ leading healthcare experts, clinicians, and technologists helping customers across 35 states manage the health and wellness of 42M+ patient lives and $4B+ in medical expenditures each year. TurningPoint empowers health plans and providers to improve the quality, safety, and affordability of healthcare.TurningPoint specializes in treating the most complex areas of care management including musculoskeletal, pain management, cardiology, wound care, oncology, ear/nose/throat, sleep, and implantable devices. Leveraging data analytics, AI, and machine learning as well as the latest advancements in telemedicine solutions, TurningPoint brings patients, providers, and health plans together to manage risk, lower costs, and drive better outcomes. Position Summary:The primary responsibility of this position is to provide determinations for medical necessity requests. This role is a 1099 contractor position and is fully remote.Roles and Responsibilities: Reviewing Pain Management cases for medical necessity. Reviewing cases which were not approved by pre-review screening process or by the initial Clinical Reviewer's algorithm. Review of pended cases to obtain all necessary clinical information, and discussion(s) with referring physicians on the appropriateness of the service requested according to the clinical criteria employed by the organization. Conducting a peer-to-peer consultation for all determinations which do not meet the criteria for approval. Rendering an adverse determination, along with justification statements for the adverse determination letter. For appeal determinations, are not the individual who made the original non-certification, nor the subordinate of such an individual; and unless expressly allowed by state or federal law, are in a state or territory of the United States when conducting appeal considerations. Conduct peer-to-peer consultations, adverse determinations, and appeals for drug utilization review, if not prohibited by state laws or the requesting party specifically requests a clinical peer. Acts as a medical resource to the Utilization Management Department staff, as needed. Acts as an active member of the quality committees, if appointed. Follows company policies and procedures. Respects and maintains HIPAA confidentiality guidelines. Other duties as directed.Education, Experience and Licensure: Physician with degrees of MDs or DOs. Current and valid non-restricted license in the USA. Some states may require state licensure to conduct reviews. Certified by the American Board of Anesthesia or the American Board of Physical Medicine & Rehabilitation Practicing in area of specialty for a minimum of five (5) years.Preferred Skills: Excellent interpersonal skills. Great communication skills. Responsible and organized individual. Exceptional writing skillTurningPoint Healthcare Solutions is an Equal Opportunity Employer.

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