Medical Doctor at Sterling Health HMO

Job Description

• Conduct medical assessments of enrollees as required for specific programs or cases.
• Provide expert medical opinions and recommendations.
• Participate in case reviews and multidisciplinary team meetings.

Utilization Review and Management:

• Evaluate the medical necessity and appropriateness of healthcare services requested by enrollees or provided by healthcare providers.
• Apply clinical guidelines and protocols to ensure cost-effective and quality care.
• Communicate with healthcare providers to clarify treatment plans and ensure adherence to guidelines.
• Authorize or pre-authorize medical services according to Sterling Health Insurance policies.
• Assist in the evaluation and credentialing of healthcare providers within our network.
• Serve as a medical liaison between Sterling Health Insurance and healthcare providers.
• Participate in provider meetings and address medical-related inquiries.
• Contribute to the development and review of medical policies, procedures, and clinical guidelines.
• Ensure that policies are evidence-based and aligned with best practices.
• Review complex or high-cost claims to ensure medical necessity and appropriate billing.
• Provide medical expertise to the claims processing team.
• Provide medical training and education to non-medical staff on relevant healthcare topics.
• Develop educational materials for enrollees on health-related issues.