Physician Reviewer MD, DO or Psy.D (Part-Time)

Alura Workforce Solutions; Rancho Cucamonga (CA); Remote; USD 120,000 - 180,000; Full time

Job summary

A leading health plan organization seeks a Physician Reviewer to support clinical decision-making and quality management initiatives. The role involves providing medical expertise, conducting reviews for medical necessity, and collaborating with Medical Directors to ensure compliance with regulatory requirements. Ideal candidates will have extensive experience in a medical specialty and possess strong knowledge of healthcare regulations.

Qualifications

• Five years post-residency experience in a recognized medical specialty required.
• Doctor of Medicine or Psy.D from an accredited institution required.
• Certification by one of the American Specialty Boards required.

Responsibilities

• Provide medical expertise and conduct medical reviews for appropriateness.
• Participate in quality improvement efforts and manage health plan resources.
• Support Medical Directors and provide clinical guidance as needed.

Skills

Medical expertise

Clinical judgement

Communication skills

Knowledge of regulations

Ability to create relationships

Education

Doctor of Medicine or Psy.D

Tools

Microsoft Office

Job description

Location : Remote (Candidates must reside in the state of California)

Schedule : Monday - Saturday, 20-25 hrs week.

Assignment Length : Up to 1,000 hours

Description

The Physician Reviewer provides support in clinical decision-making oversight and physician level guidance in quality management, utilization management, and care management. The Physician reviewer supports all Health Plan departments in meeting the regulatory requirements set forth by the various government agencies. The Physician Reviewer shall perform Medical Review activities and provide Health Plan Medical Director support. The Physician Reviewer shall perform determinations, communicate medical necessity reviews and support Health Plan Medical Director(s) as needed or requested by the Health Plan.

Commitment to Quality :

The Health Plan Team is committed to incorporate Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Key Responsibilities

• Provide medical expertise, clinical judgement and accepted medical standards in clinical decisions to ensure services provided are medically necessary and appropriate and meet professionally recognized standards.
• Conduct review of routine / urgent medical service requests based on medical necessity including but not limited to prior authorizations, inpatient care, DRG reviews, quality reviews and grievances.

Determinations shall be completed prior to the due date delineated in health plan care management system. Some due dates will also include weekend(s) and holidays.

• Turnaround times shall be in accordance with Medicare and Medi-Cal regulations.
• Perform all services in Health Plans's clinical care management systems.
• Review and provide the Medical Director support as needed and requested by health plan, i.e., policy review, committee participation or ICT support.

Reviewer shall be supported by health plan's nurse and non-clinical staff in the set up and completion of medical case reviews.

• Conduct peer-to-peer discussions regarding determinations when applicable.
• Participate in ad hoc training sessions to become familiar with Health Plans clinical care management systems.
• Provide direction of current clinical practices for health services.
• Participate in health quality improvement efforts while helping to manage health plan resources assuring an appropriate and efficient health care delivery system for health plans members and supporting strategic goals.
• Assist Medical Directors in providing medical direction and guidance to the Health Services Department in the area of inpatient, outpatient pre-service authorizations, grievances, quality reviews and the coordination of care with external agencies, consultation on complex cases, and participation in Interdisciplinary Care Teams / case conferences.
• Provide clinical support to health plan committees.
• Perform any other duties as required to ensure health plan operations and department business needs are successful, under the guidance of the Medical Director.

Responsibilities

Education & Requirements

• Five (5) years or more of post-residency experience in a recognized medical specialty required

Medical Director for an IPA, medical group, or HMO highly desirable

• Utilization management experience is a plus
• Primary Care Physician in internal medicine, family practice, or pediatrics preferred
• At least one (1) year of medical leadership experience preferred
• Doctor of Medicine or Psy.D from an accredited institution required
• Certification by one (1) of the American Specialty Boards required
• Possession of an active, unrestricted, and unencumbered Physician's and Surgeon's Certificate issued by the State of California Medical Board or a Clinical Psychologist License issued by the California Board of Psychology required.

A physician certified in a state other than California may be employed prior to receipt of California certification provided that an application for a California physician and surgeon's certificate is filed in the state of California prior to date of appointment

• Primary Care Physician in internal medicine, family practice or pediatrics preferred

Key Qualifications

• Strong knowledge of :

Medical and CMS regulations.

• Administrative practices and procedures including but not limited to quality assessment and improvement, utilization review, peer review, credentialing and risk management.
• Rules, regulations, policies, and standards related to managed care.
• Principles of effective supervision and organization.
• Methods, techniques, practices, principles, and literature in the broad field of medical sciences.
• Overview of the highly specialized techniques, procedures, and equipment used in the medical or surgical specialties
• Microcomputer applications such as Microsoft Office, Word, Excel, and Access helpful. Strong communication skills
• Ability to create and maintain positive working relationships
• While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools, or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; and taste or smell
• The employee must occasionally lift or move up to 25 pounds
• Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus

Telecommute (All positions approved for telecommute or hybrid work locations may periodically be required to report to the Health Plan's main campus for mandatory in-person meetings or for other business needs as determined by health plan leadership)

INDH

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