Medicaid Physician Review and Consulting Services

Overview The Department of Vermont Health Access (DVHA) 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. In this environment the focus is not on limiting access to care or generating profits, but rather on being good stewards of public funds by ensuring that the care provided is medically necessary and cost efficient. Time Commitment The Contractor will provide consultative services on these activities, on an as needed basis, not to exceed ten (10) hours per week, according to a mutually agreeable schedule as established by the Contractor, the State Clinical Services Team (CST) Director and the State’s Chief Medical Officer. PRIMARY RESPONSIBILITIES: 1. Review Prior Authorization (PA) requests for the medical necessity of requested medical services based on clinical acumen, DVHA clinical criteria and national guidelines. 2. Support the CST in understanding the relevance of clinical information submitted with requests. 3. Provide clinical support for review and adoption of clinical guidelines. 4. Review Non-Emergent Medical Transportation (NEMT) for medical necessity 5. Assist Vermont Chronic Care Initiative (VCCI) nurse case managers with questions related to management of patient conditions. 6. Participate in monthly VCCI case reviews and prepare brief presentation related to the monthly topic. 7. Conduct Peer to Peer discussions with requesting providers regarding coverage determinations. 8. Participate in the Appeals and Fair Hearings as needed. 9. Participate in quality improvement activities as needed. Competencies, Knowledge, Skills & Abilities Experience and Subject Matter Expertise • Attainment of M.D. or D.O. degree and a minimum of one-year primary care or general medicine internship. Board Certification in an ABMS approved specialty is preferred. • Current license to practice medicine in Vermont • Meets Vermont Medicaid credentialing standards • Expert knowledge of care management and quality improvement programs • Understanding of national and Vermont health reform initiatives • Experience treating patients with acute and complex medical needs, such as but not limited to co-occurring substance use disorder, mental health, and medical disorders and conditions. • Familiarity with electronic health record systems Qualifications – Qualified candidates must possess an M.D. or a D.O. with an active Vermont medical license in good standing. Preference given to candidates with broad practice experience (primary care/general internal medicine) and/or previous experience making medical necessity determinations.