Orthopedic Surgery Senior Physician Advisor - AIM - 135902

Anthem, Inc. Glendale, CA
This position may be located in Westchester or Deerfield, IL; or in Glendale, CA

Your Talent. Our Vision. At AIM Specialty Health (AIM), a proud member of the Anthem, Inc. family of companies, it's a powerful combination, and the foundation upon which we're creating greater care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care. This is an exceptional opportunity to do innovative work that means more to you and those we serve.

AIM is currently seeking a Board-Certified Orthopedic Surgeon to participate in pre-authorization and quality improvement solutions for musculoskeletal procedures involving the spine and joints, and high-tech diagnostic imaging. Physician Advisors determine the medical necessity of requests using clinical appropriateness guidelines and health plan medical policy.

Successful candidates will:

* Determine medical necessity of requests using applicable clinical criteria, which may include AIM Appropriateness Guidelines, client-specific health plan medical policy, well established evidenced based guidelines and CMS Coverage Determinations, as applicable.

* Perform physician-level case review of musculoskeletal utilization requests involving the spine and joint and high-tech diagnostic imaging following initial clinical review by a physical therapy reviewer or a nurse reviewer.

* Conduct peer-to-peer consultations with ordering physicians, physician assistants and advanced practice nurses regarding established guidelines and accepted standards of care as it relates to treatments, surgical procedures, imaging and appropriate sites of service.

* Discuss clinically appropriate alternative surgical and non-surgical treatments, imaging studies and sites of care with ordering providers when consistent with applicable clinical criteria.

* Provide education regarding applicable clinical criteria.

* Perform first level provider appeals of coverage decisions.

* Demonstrate and maintain knowledge of applicable clinical criteria and relevant AIM policies pertaining to utilization review.

* Demonstrate and maintain knowledge of applicable ICD-10, HCPCS and CPT coding guidelines as it relates to musculoskeletal services and procedures.

* Provide support and educate internal clinical and non-clinical staff to foster understanding of the principles associated with appropriate musculoskeletal diagnoses, treatments and management.

* Actively participate in physician team meetings.

* Actively participate in groups that develop, revise and enhance clinical appropriateness guidelines.

* Obtain additional state licensure based upon state regulations and health plan needs.

* Adhere to all AIM Specialty Health protocols, policies, and procedures.

About AIM Specialty Health

AIM Specialty Health (AIM) is a leading specialty benefit management company that promotes appropriate, safe and affordable healthcare services. We are a member of the Anthem family of companies, which is recognized as one of the nation's leading health benefits companies.

AIM provides innovative clinical solutions that focus on today's most complex and costly tests and treatments in radiology, cardiology, medical and radiation oncology, specialty drugs, sleep medicine, musculoskeletal and pain management, genetic testing, palliative care, and other emerging clinical areas.

With evidence-based medicine, technology, people and processes, we support clinical appropriateness review, provider collaboration and member engagement on behalf of more than 50 health plans, 40% of the Fortune 50 Employers, and 43 million members.

Today, our team includes more than 1,100 associates and features more than 600 licensed and board-certified physicians, nurses, and other healthcare professionals who engage with more than 330,000 health care providers across the country. These healthcare providers access our solutions and specialized clinical expertise through our online ProviderPortal and experienced contact center-based teams that is enabled by our business platform.

Our pioneering spirit and dedication to improve health care continues to produce significant industry-first advancements, quality recognition achievements, and high satisfaction rates. AIM is certified by the National Committee for Quality Assurance (NCQA) and has received Full Accreditation for Health Utilization Management from the Utilization Review Accreditation Commission (URAC.)

We maintain offices in Chicago, Deerfield, Schaumburg and Westchester, IL, as well as Glendale, CA.

To learn more, visit www.aimspecialtyhealth.com.

Qualified Candidates will have:

* Current unrestricted medical license(s) as a Doctor of Medicine or Doctor of Osteopathic Medicine in an appropriate state.

* Board Certification in Orthopedic Surgery by the American Board of Orthopedic Surgery or American Osteopathic Board of Orthopedic Surgery.

* 3-5 years of clinical practice experience past fellowship training is desirable.

* Independent performance of standard orthopedic surgical procedures.

* Fellowship in spine surgery or extensive spine surgery experience is desirable.

* Demonstrated knowledge of current practice standards in orthopedics.

Anthem, Inc. is ranked as one of America's Most Admired Companies among health insurers by Fortune magazine and is a 2017 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at antheminc.com/careers. EOE. M/F/Disability/Veteran.