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Hematologist
Maximus
- New York, New York, United States
- New York, New York, United States
About
Description
Medical Expert Reviewer-Medical Expert Judgement Reviews determining final decision based off enrollee’s denial of treatment coverage denied by the CA DMHC.
Reviews are based off Medical Necessity and Experimental/Investigational.
Specialty Driven-Expert within the Specialty Requested.
This service involves getting a thorough and professional medical review from an expert provider. The review is done to make a final decision on whether a particular treatment should be covered by the CA DMHC (Department of Managed Health Care) or not. The reviews are based on two main factors: medical necessity (whether the treatment is necessary for the patient's health) and whether the treatment is experimental or investigational.
Systems and Tools
Expert Reviewers must use their own personal computer to access a web-based portal.
Review Training –Trainer will work closely with reviewer for the first 3-5 cases.
Scheduled Training- based on reviewer’s schedule.
No direct defined evidence standard or guidelines.
Templates will be used to complete reviews.
Provider Specialty Minimum Qualifications
24 hours of direct patient care per week.
5 years’ experience in appropriate specialty post training.
Medical Necessity Review: Standard Case Most common type of review.
30 – 45 minutes to complete.
5 – 7 days to turnaround.
Medical Necessity Review: Expedited Case Sickest patients 24-hour turnaround.
45 min - 1 hour to complete.
Experimental/Investigational Reviews: Standard Case Second most common review.
1-2 hours to complete (based on experience).
5 - 7-day turnaround.
Volume: Varies based on need.
Experimental/Investigational Reviews: Expedited Case Sickest of patients 24-hour turnaround.
1-2 hours to complete (based on experience).
For more information about Maximus, please visit https://maximus.com/ to learn more about our organization.
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Languages
- English
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