Medicare Advantage UM Physician (Remote)

SCAN Health Plan; Long Beach (CA); Híbrido; USD 207.000 - 276.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Mostly remote work

401(k) with employer match

HQ visits to Long Beach, CA

Descripción de la vacante

SCAN Health Plan is seeking a Physician to lead utilization management decisions for prior authorization, concurrent and retrospective reviews. You will discuss cases with treating physicians, ensure determinations align with Medicare rules, MCG criteria, and plan policies, and support timely, evidence-based decisions.

The role requires senior clinical experience, strong collaboration with RN staff, and a commitment to regulatory standards. Mostly remote with monthly HQ visits in Long Beach.

Formación

• Medical license required and active in good standing.
• 5+ years active clinical practice in Internal Medicine, Family Medicine, or Emergency Medicine.
• 2–3 years in utilization management in a health plan environment.
• Experience with MC G criteria and NCQA/URAC frameworks.
• Ability to conduct peer-to-peer discussions and provider education.

Responsabilidades

• Perform physician-level medical necessity review of prior authorization requests.
• Render determinations per Medicare guidelines and MC G criteria (MCG).
• Conduct peer-to-peer discussions with treating providers and document clinical rationale.
• Serve as reviewer for first-level appeals and participate in ALJ hearings as required.
• Mentor RN reviewers and intake staff; escalate complex cases.

Conocimientos

Medical license

Utilization management

Peer-to-peer review

MCG criteria knowledge

Regulatory compliance

Communication skills

Mentoring / leadership

Educación

MD/DO

Board certification

Herramientas

UM/clinical workflow platforms

EHR systems

Descripción del empleo

SCAN Health Plan is seeking a Physician to lead utilization management decisions for prior authorization, concurrent and retrospective reviews. You will discuss cases with treating physicians, ensure determinations align with Medicare rules, MCG criteria, and plan policies, and support timely, evidence-based decisions.

The role requires senior clinical experience, strong collaboration with RN staff, and a commitment to regulatory standards. Mostly remote with monthly HQ visits in Long Beach.