CVS Health Durable Medical Equipment Clinical Consultant in Dallas, Texas
Conducts clinical reviews and provides input and oversight for clinical policy implementation for a medical specialty (e.g. Prosthetics/Orthotics). Participates in the development, implementation, and evaluation of clinical programs that are specific to that medical discipline. Excludes nursing, physician, behavioral health, dental, pharmacy and physical/occupational therapy roles which are reflected in alternate job descriptions.
Determines medical necessity and appropriateness (may include prospective, concurrent, retrospective review/analysis of program submissions, claims)
Provides clinical expertise for medical discipline for preservice reviews and reviews of claim determinations and in support of program and benefit utilization and improvements goals
Consults and lends clinical expertise to colleagues and other internal and external constituents
Utilizes clinical experience and skills in a collaborative process across the Enterprise to evaluate and facilitate appropriate healthcare services/benefits for members
Coordinates/Communicates with providers and other parties to facilitate optimal care/treatment
Educates and empowers colleagues at all levels to enable decision making at most appropriate level.
Render opinions on emerging specialty trends, utilization review, plan coverage, network management, claims policy and standards of care and develop, implement, and evaluate policies and procedures, which meet business needs
3+ years clinical practice experience, e.g. hospital, professional practice.
Assistive Technology Certification
Seating & Mobility Specialist Certification
Managed care/claims review experience preferred
Percent of Travel Required
0 - 10%
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