Medicaid Physician Review and Consulting Services

The Department of Vermont Health Access is soliciting proposals to contract with an actively licensed Physician(s) to provide medical oversight related to the clinical needs of the department, provide prior authorization case review and medical necessity determinations in a Medicaid Managed Care environment. The contractor will provide consultative services on an as-needed basis, not to exceed ten hours per week. The contractor will be responsible for reviewing prior authorization requests, supporting the Clinical Services Team, providing clinical support for review and adoption of clinical guidelines, and participating in quality improvement activities. • Reviewing prior authorization requests for medical necessity • Supporting the Clinical Services Team in understanding clinical information • Providing clinical support for review and adoption of clinical guidelines • Reviewing Non-Emergent Medical Transportation for medical necessity • Assisting Vermont Chronic Care Initiative nurse case managers with questions related to patient conditions • Participating in monthly case reviews and preparing brief presentations • Conducting Peer to Peer discussions with requesting providers regarding coverage determinations • Participating in Appeals and Fair Hearings as needed • Participating in quality improvement activities as needed The ideal candidate will have an M.D. or D.O. degree, a minimum of one-year primary care or general medicine internship, and a current license to practice medicine in Vermont. The candidate should also have expertise in care management and quality improvement programs, understanding of national and Vermont health reform initiatives, and experience treating patients with acute and complex medical needs.