Physician Reviewer - Appeals Unit (PT)
Avalon Healthcare Solutions
Avalon Healthcare Solutions, headquartered in Tampa, Florida, is the world’s first and only Lab Insights company, bringing together our proven Lab Benefit Management solutions, lab science expertise, digitized lab values, and proprietary analytics to help healthcare insurers proactively inform appropriate care, reduce costs, and improve clinical outcomes. Working with health plans across the country, the company covers more than 36 million lives and delivers 7-12% outpatient lab benefit savings. Avalon is pioneering a new era of value-driven care with its Lab Insights Platform that captures, digitizes, and analyzes lab results in real time to provide actionable insights for earlier disease detection, ensuring appropriate treatment protocols, and driving down overall cost.
Studies show that 30% of clinical laboratory testing is unnecessary or overused. Inappropriate testing or missing a key screening can lead to complications and expense arising from unwarranted care, or not obtaining proper care when needed, leading to increased health risks and costs. Avalon helps ensure delivery of the right test, at the right time, and in the right setting. We seek to ensure the most effective patient treatment, improve clinical outcomes, and optimize cost and affordability.
Avalon is a portfolio company of Francisco Partners, a global private equity firm that specializes in investments in technology and technology-enabled service companies.
Avalon is a high growth company where every associate has an opportunity to make a difference. You will be part of a team that shapes a new market and business. Most importantly, you will help Avalon to achieve its mission and improve clinical outcomes and health care affordability for the people we serve.
For more information about Avalon, please visit www.avalonhcs.com.
Avalon Healthcare Solutions is proud to be an equal opportunity employer including disability/veteran. We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender identity or Veteran status.
Avalon Healthcare Solutions provides and maintains a drug-free workplace for its employees.
For more about Avalon, please visit our web site at http://www.avalonhcs.com.
About the Physician Reviewer Position:
Applies health plan medical policies and criteria to make medical necessity decisions and verifies that preservice requests are compliant with the American Medical Association® (AMA) laboratory testing guidelines.
This position is eligible for remote work, but quarterly travel to the corporate office in Tampa, Florida may be required.
This is a Part-Time position.
Physician Reviewer - Essential Functions and Responsibilities:
- Reviews preservice laboratory testing services requests for medical necessity and correct coding
- Serves as a resource for information and consultation on Preservice review issues
- Consults with ordering provider during Peer-to-Peer reviews
- Documents decision rationale for members and providers in clear, concise and understandable language
- Other duties as assigned or requested
Physician Reviewer - Minimum Qualifications:
- Five (5) years’ experience in healthcare delivery performing preservice reviews
- MD or DO with a current, unrestricted medical license
- Board certified in an American Board of Medical Specialties or Bureau of Osteopathic Specialists recognized specialty
- Attend and participate in meetings by phone, computer, or in person. Excellent communication skills including good grammar, voice and diction. Ability to navigate and master proprietary software programs and proficient in MS Office with basic computer and keyboarding skills.
Physician Reviewer - Preferred Qualifications
- It is desirable that the candidate maintains some level of active clinical practice.