Clinical Review Physician – Utilization & Care Management

Kaiser Permanente; Renton (WA); On-site; USD 180,000 - 240,000; Full time

Job summary

Kaiser Permanente is seeking a Clinical Reviewer to adjudicate coverage requests using established criteria and contract language. You will document decisions, communicate rationale, and work with regional leaders to ensure timely reviews.

The role requires an MD or DO with residency in internal or family medicine, Washington license, and experience in utilization/quality management. Strong collaboration and communication are essential.

Qualifications

• MD/DO with license to practice in Washington state
• Residency in internal or family medicine completed
• Training in health plan review, utilization management, and quality programs

Responsibilities

• Conducts clinical reviews of coverage requests using criteria and timelines
• Documents review outcomes and rationale for patient and provider letters
• Coordinate with external delivery system on referral and review processes
• Manage standard and expedited patient appeals within regulatory timelines
• Participate in Administrative Law Judge hearings when needed
• Collaborate with guidelines, technology, and pharmacy committees on new services

Skills

Clinical review

Regulatory standards

Communication

Collaboration

Quality management

Education

Medical Degree MD/DO

Residency in internal or family medicine

Certificate in health plan review or quality programs

Advanced degree recommendations (MBA/MHA/MPH)

Job description

Kaiser Permanente is seeking a Clinical Reviewer to adjudicate coverage requests using established criteria and contract language. You will document decisions, communicate rationale, and work with regional leaders to ensure timely reviews.

The role requires an MD or DO with residency in internal or family medicine, Washington license, and experience in utilization/quality management. Strong collaboration and communication are essential.