The Phyisician Support Lead is a Philippine based physician responsible in providing medical expertise in the operation of Utilizaton Management programs in accordance with regulatory, state, corporate and accreditation requirement.
Establishes and maintains a visible presence by working closely with the Clinical Competency Leaders, Operations Delivery Managers and Utilizaton Management personnel through active participation on various Utilization Management clinical activities
Works with UM clinical personnel to identify appropriate use of clinical guidelines, criteria and medical policies
Provides evidence-based clinical teaching or case presentation to the nurse reviewers in understanding diagnoses and requested procedures / services for needed areas of improvement
Provides education on utilization management review process (e.g., clinical review documentation for case referrals to client’s Medical Directors) to the UM clinical and non-clinical personnels
Participates in case discussion and provides / recommends appropriate direction to review the case
Acts as a consultant for the clinical staff / nurse reviewers regarding their decision on the patient’s care and clinical review documentation
Perform Root Casuse Analysis when case issues arise due to lack of case understanding or guideline / policy interpretation
Moderates and / or leads in a regular clinical rounds with the nurses to discuss trending errors from audits or client escalations
Interacts with client’s Medical Director and Clinical Leaders and acts as a liaison between CTS nurse reviewers and Client’s MD as needed
Serves as additional resource in the development of training materials and regular product knowledge health examinations
Assists in creation and implementation of Quality Improvement Plans
The position is to drive client clinical satisfaction and Cognizant Technology Solutions (CTS) clinical outcomes.
Responsible for developing client clinical relationship strategies.
Lead physician to interface between and liaison with CTS and clients.
Collaborate with CTS operational leadership to align CTS’ clinical organizational management with client’s clinical organizational management for operational efficiencies and clarity of workflow.
Clinical business partner for CTS and client’s operational and clinical leaders.
Partner and collaborate with the CTS Senior Leadership and client in planning, implementation and evaluation / modification of existing clinical operations, systems and procedures to ensure clinical client satisfaction
Provides clinical expertise in support of medical management programs Pre- service, Concurrent, and Retrospective Reviews, Appeals, Case Management, Disease Management, Pharmacy, Skilled Nursing Facility (SNF), Home Health Care, Durable Medical Equipment (DME), Long-term Service and Support (LTSS), and other clinical programs.
Clinical advisor to clinical staff - provide education, clarifications on clinical information or guidelines as needed
Liaison between the client’s medical leadership and CTS.
Participate in of the medical management Governance teams, when appropriate
Collaborates with regulatory affairs, legal, and compliance to ensure that applicable accreditation, state and federal requirements are in compliance
Part of the team to select program management staff
Works collaboratively with other functional areas within CTS that interfaces with medical management / Global Clinical Services (GCS)
Respond to escalation for clinical issues; addresses and resolves issues and clinical complaints
Gives guidance to CTS leadership and staff on US Healthcare Delivery
Collaborating with CTS training and quality teams and working with CTS nursing staff to ensure the nurses are able to make sound clinical judgments based on the clinical information provided and medical criteria InterQual, MCG, Medicare, Medicaid, or plan specific medical policies)
Optimize nurse presentation skills
Once nurse clinical deficits are identified work with quality and training staff to eliminate or improve those deficits.
Review clinical scorecards and performance metrics with clinical leaders and help create action plans with timely resolution.
Assist in providing coaching, mentoring, performance management and feedback to clinical nurses and staff to ensure associates are working toward improving CTS’ business.
Participate in CTS educational rounds
Be available to discuss cases prior to sending to the client medical director and after, as needed
Clinical Quality Oversight
Provides oversight for accreditation (URAC / NCQA) and URO licenses.
Provides clinical expertise in support of medical management program through participation in clinical team activities
Actively participates in quality management process (including, but not limited to, the Quality Management Committee) and identification of opportunities for improvement to ensure compliance with established utilization management standards and client requirements.
Communicates with the client UM Medical Director and client Clinical staff, as needed
Participates in ongoing analysis of Inter-Rater Reliability reporting and quality improvement including but not limited to sharing UM information for the QM program as evidenced by the established QM work plan activities.
Provide oversight and guidance regarding Quality Management Projects ( QMP ) and Quality Improvement Projects ( QIPs ) under the ownership of the Quality Management Committee.
Works with the Quality Management Committee to approve, initiate, review progress, and oversight proposed QMPs and QIPs in accordance with accrediting bodies through review of monitoring and auditing performed by the Committee.
This review will be performed at least annually.
With the Quality Management Committee, evaluates QMP and QIP at least annually for effectiveness and to take action on areas for improvement identified.
Through monitoring and auditing performed by the Quality Management Committee,
Actual and potential nonconformities to the quality program will be identified and corrective or preventive actions will be recommended to the Committee to be implement.
Recommendations only made to address areas for improvement based on results of QMP and QIP.
Participates in their review and approval of clinical policies and SOP’s.
Works with the Quality Management Committee to facilitate receiving, documenting, and responding to relevant QMP communication (Both internal and external).
Provide guidance to clinical staff on quality related questions related to clinical reviews
vii. Approves the clinical quality improvement projects on an annual basis.
viii. On an ongoing basis evaluates the effectiveness of the UM Program and makes updates as needed.
ix. Establishes, reviews and approves Cognizant’s policies & procedures at minimum annually, in accordance to URAC accreditation requirements.
x. Conducts and participates on client clinical rounds and communicates all relevant utilization and quality issues to the appropriate individuals and / or committees.
xi. Provides clinical oversight and is accessible to clinical staff.
xii. Identifies areas for improvement to ensure compliance with established utilization management standards and client requirements.
xiii. Facilitates the development of corrective action plans, implementation and ongoing monitoring.
Educational & Job Qualifications
Must have a Bachelor’s degree in Medicine
Philippine based Physician will have active and unrestricted MD licenses to practice in the Philippines.
At least five (5) years of clinical and or Utilization Management Review experience preferred
Knowledge of different US clinical guideline and criteria such as MCG, Interqual protocols, CMS NCD and LCD, MTUS and Health Plan Medical Policies
Knowledge of US managed care and principles and processes
Effective written and oral communication skills and be able to maintain confidentiality
Demonstrated PC knowledge including Windows, MS Applications - Microsoft Word, Excel, and Outlook
Minimum typing speed of 30 wpm with 5% errors or less
Willingness to render extended hour / s as the need arises
Knowledge of American culture
Job Location : Taguig, Metro Manila, Philippines Makati City, National Capital Region, Philippines