Clinical Review Physician - Utilization & Care Management

Southern California Permanente Medical Group; Renton, Northern (WA, KY); Hybrid; USD 90,000 - 150,000; Part time

Job summary

Washington Permanente Medical Group in Renton, WA is seeking a part-time Clinical Reviewer Unit Physician to adjudicate coverage requests using professional criteria and contract language.

You will document reviews and decisions for patient and provider communications within established timelines, and collaborate with care management, RN’s, and medical staff to ensure appropriate levels of care and timely determinations.

Qualifications

• Minimum 3+ years of clinical practice including outpatient primary care and utilization/quality management.
• Experience leading teams in analysis, planning, implementation and monitoring of new programs and processes.
• Knowledge of regulatory and certification requirements impacting utilization management, referral management and care coordination design.

Responsibilities

• Conducts clinical reviews on potential coverage denials using established criteria within regulatory timelines.
• Documents review process and decisions with rationale for patient and provider letters within predefined timelines.
• Collaborates with external delivery system to clarify referral and review processes and outcomes.
• Manages standard and expedited patient appeals within regulatory timelines; participates in Administrative Law Judge hearings as needed.
• Ensures understanding of health plans, contract language, and managed care in an integrated group practice.

Skills

Clinical review

Utilization management

Quality programs

Team collaboration

Education

MD/DO

Residency in internal or family medicine

Training in health plan review

Job description

Washington Permanente Medical Group in Renton, WA is seeking a part-time Clinical Reviewer Unit Physician to adjudicate coverage requests using professional criteria and contract language.

You will document reviews and decisions for patient and provider communications within established timelines, and collaborate with care management, RN’s, and medical staff to ensure appropriate levels of care and timely determinations.