Clinical Review Physician: Utilization & Coverage Lead

Kaiser Permanente - Washington Permanente Medical Group (WPMG); Renton (WA); On-site; USD 110,000 - 140,000; Full time

Job summary

Washington Permanente Medical Group, a KP health plan partner, seeks a Clinical Reviewer to adjudicate coverage requests using established criteria. You will document decisions with clear rationale for communications and collaborate with care managers to ensure appropriate levels of care across hospital and community settings.

Minimum MD/DO with internal or family medicine residency; experience in utilization management and quality programs is preferred.

Qualifications

• MD or DO with accredited residency in internal or family medicine.
• Documentation of additional training in health plan review, utilization management, and quality programs.

Responsibilities

• Conduct clinical reviews on potential coverage denials using clinical review criteria.
• Document the review process and decisions with rationale for patient and provider communications.
• Coordinate with external delivery system to align referral and review processes.
• Manage standard and expedited patient appeals within regulatory timelines.

Skills

Clinical review

Documentation

Regulatory knowledge

Effective communication

Team collaboration

Project management

Quality improvement

Negotiation

Education

MD/DO

Internal or family medicine residency

Health plan review / utilization management training

Certificate of Medical Management / MBA / MHA / MPH

Job description

Washington Permanente Medical Group, a KP health plan partner, seeks a Clinical Reviewer to adjudicate coverage requests using established criteria. You will document decisions with clear rationale for communications and collaborate with care managers to ensure appropriate levels of care across hospital and community settings.

Minimum MD/DO with internal or family medicine residency; experience in utilization management and quality programs is preferred.