It takes a lot of moving parts to move the needle on the healthcare system. Here are some of the groups working to improve the quality of life. See which one is the right fit for you.
Our Associate Medical Directors are empowered to make a difference in people’s lives by improving the quality of care for patients, providers, and payers. This team reviews clinical requests. Physicians review cases on the eviCore portal or on peer-to-peer calls to determine the appropriate evidence-based clinical decision. This model allows Associate Medical Directors to make a difference by supporting over 100M patients annually.
Nurse Clinical Reviewers are responsible for all clinical certification activities, which include assessing requests for authorization of clinical services from various healthcare professionals, comparing requests against established clinical protocols, and authorizing services or referring requests for expert clinical review as appropriate. Decisions and determinations are consistent with eviCore’s policies and URAC and NCQA principles. If criteria are not met, the Clinical Reviewer will refer to physician review.
Our Genetic Counselors are responsible for laboratory molecular and genetic testing clinical case review activities, which include evaluating requests for authorization of coverage of molecular and genetic laboratory requests, comparing requests against established clinical protocols, and authorizing coverage of services or referring requests for expert clinical review as appropriate. Our Genetic Counselors serve physicians and labs as expert advisors on the appropriate use of genetic testing, including new and cutting-edge tests entering the market.
Post-Acute Care manages patients for up to 90 days following discharge from the acute setting.
PAC provides dedicated nurse case managers and nursing support, personalized plans of care, and re-admission prevention. Areas of expertise include:
Clinical reviewers are responsible for performing prospective and retrospective reviews given clinical information to determine the medical necessity of skilled care for physical, occupational, and speech therapy services. Determinations are consistent with eviCore’s clinical review protocols and guidelines and follow URAC standards. Responsibilities also include completing peer-to-peer consultations with providers.