Clinical Review Physician: Utilization & Quality Leader

Kaiser Permanente - Washington Permanente Medical Group (WPMG); Renton (WA); On-site; USD 140,000 - 210,000; Full time

Job summary

Kaiser Permanente Washington Permanente Medical Group (WPMG) seeks an experienced Clinical Reviewer Unit Physician to adjudicate coverage requests using professional standards. You will document outcomes, work with care management and regional leaders, and contribute to utilization review and quality programs.

The role requires a medical degree and residency in internal or family medicine, with knowledge of health plan review and managed care environments.

Qualifications

• MD/DO with accredited residency in internal or family medicine.
• Documentation of training in health plan review and utilization management.
• Board Certification by ABMS or equivalent and Kaiser Permanente credentialing.

Responsibilities

• Conduct clinical reviews of coverage requests using established criteria.
• Document review processes and rationales for patient/provider letters.
• Collaborate with KPWA staff and external delivery systems on review processes.
• Manage patient appeals within regulatory timelines and involve specialists as needed.
• Participate in administrative law judge hearings when required.
• Engage with guidelines, pharmacy and therapeutics committees to assess new services.
• Assist in weekend calls via telephone and computer.

Education

Medical Degree: MD, DO

Residency in internal or family medicine

Certificate of Medical Management / MBA / MHA / MPH

Job description

Kaiser Permanente Washington Permanente Medical Group (WPMG) seeks an experienced Clinical Reviewer Unit Physician to adjudicate coverage requests using professional standards. You will document outcomes, work with care management and regional leaders, and contribute to utilization review and quality programs.

The role requires a medical degree and residency in internal or family medicine, with knowledge of health plan review and managed care environments.