Physician Reviewer II, Quality Management (Per Diem)

L.A. Care Health Plan; Los Angeles (CA); On-site; USD 206,000 - 351,000; Full time

Benefits offered by this job

Paid Sick Leave

457 (b) Retirement Plan

529 College Savings Plan

Job summary

L.A. Care Health Plan in Los Angeles invites a Physician Reviewer II to conduct medical reviews and provide clinical consultation under the Senior Medical Director. The role emphasizes utilization management, approvals, and coordinating with care teams.

The position requires an MD, California license, leadership abilities, and experience with safety-net populations. You will contribute to quality care and regulatory compliance within a large public health plan.

Qualifications

• MD degree required and California medical license active and unrestricted.
• Experience leading physicians, nurses and health care professionals.
• Experience with Medicaid managed care and safety net populations preferred.

Responsibilities

• Conduct medical reviews and prepare determinations on utilization management, pharmacy, and prior authorizations.
• Provide clinical consultation to case management staff and other L.A. Care staff.
• Review data to improve Medical Management programs and processes.
• Participate in Concurrent Review and Interdisciplinary Care Team rounds and regulatory compliance activities.

Skills

Leadership

Teamwork

Communication

Collaboration

Education

Doctor of Medicine (M.D.)

Job description

Salary Range: $206,311.00 (Min.) - $278,520.00 (Mid.) - $350,729.00 (Max.)

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.

Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.

Job Summary

The Physician Reviewer II shall conduct medical reviews, clinical consultation and other medical consultation work as necessary under the general direction of the Senior Medical Director, Medical Management, as more specifically described below.

Duties

• Conduct medical reviews and prepare determinations (including written criteria/reasons for determinations) on utilization management, pharmacy, prior authorizations, retrospective authorizations, member and provider appeals and state fair hearings and potential quality incidents (PQI).


• Assist the Senior Medical Director, Medical Management, in oversight of the management of clinical grievances and Medi-Cal state fair hearings.


• Provide clinical consultation to case management staff and other L.A. Care staff as needed.


• Review and identify data that can assist and improve Medical Management programs and processes.


• Assist with the oversight and support of the Medical Management programs and processes.


• Develop and lead projects as agreed upon.


• Provide other medical consultation work as assigned by Senior Medical Director, including but not limited to review of member communications and health education materials for clinical appropriateness and accuracy.


• Participates in Concurrent Review and Interdisciplinary Care Team (ICT) Rounds.


• Participates in Inter-Rater Reliability (IRR) Rounds as required as well as other activities that are necessary for health plan compliance with regulatory standards.


• Perform other duties as assigned.

Education Required

Doctor of Medicine (M.D.)

Preferred

• Experience with Medicaid managed care and/or other governmental programs for underserved, safety net populations including women, children, persons with disabilities, seniors, and those of varied ethnic and cultural backgrounds.


• Experience in managing staff and operations.

Skills

Required:

• Ability to provide leadership to physicians, nurses, and other health care professionals, and interest and involvement in the affairs of the health care community.


• Demonstrated ability for teamwork and collaborative problem-solving.


• Excellent written and verbal communications skills, negotiating skills, consensus building and teamwork, planning and implementation skills.


• Ability to work collaboratively internally and externally to achieve results is critical.

Licenses/Certifications Required

• Board Certified, preferably in a primary or medical specialty - Active, current and unrestricted California license.


• Clinical License to practice or an Administrative License to review Utilization Management cases. - Active, current and unrestricted California License

Physical Requirements

Light

Salary Range Disclaimer

The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.

L.A. Care Offers a Wide Range Of Benefits Including

• Paid Sick Leave


• 457 (b) Retirement Plan


• 529 College Savings Plan