Clinical Review Physician – Utilization & Quality

Kaiser Permanente - Washington Permanente Medical Group (WPMG); Renton (WA); On-site; USD 190,000 - 230,000; Full time

Job summary

Kaiser Permanente - Washington Permanente Medical Group (WPMG) is seeking a Physician in the Clinical Reviewer unit to adjudicate coverage requests using professional criteria. The role involves documenting decisions, interacting with care teams, and supporting regulatory timelines.

The position emphasizes clinical judgment, knowledge of utilization review, and collaboration with hospital and care management teams within KPWA network.

Qualifications

• Medical Degree: MD or DO required.
• Accredited residency in internal or family medicine completed.
• Documentation of additional training in health plan review, utilization management, and quality programs (e.g., Certificate of Medical Management, MBA, MHA, MPH).

Responsibilities

• Conducts clinical reviews on potential coverage denials using established criteria and timelines.
• Documents review process and decisions with rationale for patient/provider letters.
• Collaborates with external delivery system to align referral and review processes.
• Manages standard and expedited patient appeals within regulatory timelines.
• Participates in Administrative Law Judge hearings when needed.
• Familiar with hospital management, case management, utilization review, and quality management.

Education

Medical Degree: MD, DO

Residency in internal or family medicine

Training in health plan review/utilization management/quality programs

Job description

Kaiser Permanente - Washington Permanente Medical Group (WPMG) is seeking a Physician in the Clinical Reviewer unit to adjudicate coverage requests using professional criteria. The role involves documenting decisions, interacting with care teams, and supporting regulatory timelines.

The position emphasizes clinical judgment, knowledge of utilization review, and collaboration with hospital and care management teams within KPWA network.