Job Description

Location

Work from Home LR Based - Little Rock, AR 72201 US (Primary)

SCOPE OF POSITION

Perform initial and reconsideration reviews for private and Medicaid contracts. Develop relationships and promote mutually beneficial partnerships with employees, clients, other healthcare organizations, and the community at large. Support the organization’s mission, vision, and values by exhibiting the following behaviors: Honesty, Excellence, Accountability, Respect and Teamwork. This position is work from home.

ESSENTIAL JOB FUNCTIONS

• Perform initial and reconsideration reviews for private and Medicaid contracts.
• Review pertinent medical record and represent the details of the rationale provided by external physician reviewers as testimony based on that review in an open court proceeding (i.e., fair hearing). Fair hearings could require an in-person appearance if requested.
• Facilitate mission goals across teams at the organizational level.
• Meet regularly with the Medical Director of Clinical Services to stay informed, to offer direction and support for inter‑departmental projects, and to confer on organizational goals, objectives, and policies.
• Develop relationships and promote mutually beneficial partnerships with clients, other health care organizations, and the community at large.
• Confer with the Medical Director and management to identify and develop new opportunities for expanding the business. Monitor current contracts and clients to identify and establish “new business” goals and revenue growth opportunities.
• Function as a resource for clinical and non‑clinical staff by providing oversight and follow‑up for clinically related questions or issues.
• Support and advise Clinical Services staff.
• Participate in peer‑to‑peer clinical review phone conversations, as necessary, to meet contractual obligations.
• Ensure compliance with AFMC policy, contractual obligations, and state and federal laws and regulations.
• Maintain current knowledge of corporate contracts with emphasis on opportunities for new business.
• Attend Board Meetings upon CEO request.
• Adhere to format, content, and style guidelines, ensuring accuracy, consistency, and quality.
• Follow AFMC, state, and federal protocols regarding data confidentiality/security and HIPAA compliance.
• Additional duties as assigned.

KNOWLEDGE, SKILLS, AND ABILITIES

• Intermediate skill level with MS Office (Word, Excel, Outlook, and PowerPoint)
• Type 40 wpm
• Exceptional skills in business English, spelling, punctuation, and grammar.
• Knowledge of regulations and contract requirements pertaining to the assigned area of responsibility
• Ability to lead and participate in multi‑disciplinary team projects
• Well‑developed planning, organizational development, and business skills
• Ability to negotiate and reach mutually agreeable solutions
• Ability to maintain confidentiality
• Coaching skills
• Creativity
• Ability to delegate as required
• Ability to meet deadlines
• Flexibility
• Ability to work collaboratively and independently to achieve stated goals
• Initiative
• Ability to relate professionally and positively with staff, business partners, customers, recipients, and the public
• Knowledge of ICD‑9/ICD‑10 Coding
• Knowledge of HIT/EHR
• Medical terminology
• Ability to prioritize
• Professionalism
• Strong public speaking skills
• Ability to travel, including overnight travel.

Physical and sensory requirements (with or without the aid of mechanical devices)

Mobility, reaching, bending, lifting, grasping, ability to read and write, ability to communicate with personnel, ability to remain calm under stress. Must be capable of performing the essential job functions of this job, with or without reasonable accommodations.

EDUCATION

Required : Current unrestricted clinical license in the state of Arkansas as a Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO). Must be Board certified.
Desirable : Master’s degree in public health, healthcare administration, or business administration

EXPERIENCE

Required : Five (5) years full‑time equivalent direct patient care experience and direct patient care experience within the previous three (3) years. Must be a practicing physician involved in direct patient care.
Preferred : Two years of experience in medical review, quality improvement, or health care management. Experience in providing professional testimony in a legal setting. Experience and knowledge of Medicaid and other major managed health care programs.

INTERNET REQUIREMENTS

Reliable, high‑speed wireless internet service (Wi‑Fi)

Equal Opportunity Employer/Veterans/Disabled EEO IS THE LAW

AFMC, Inc. is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against on the basis of disability or any other status protected by federal, state and/or local law. AFMC invites any employee and/or applicant to review the Company’s Affirmative Action Plan . This plan is available for inspection upon request, which may be made in person or by telephone (501) 212‑8796, by fax (501) 212‑8797 or by U.S. mail Attn: Human Resources, 1020 West 4th Street, Suite 400, Little Rock, AR 72201.

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