Physician Reviewer MD, DO or Psy.D (Part-Time) 25-00279

Alura Workforce Solutions; Rancho Cucamonga (CA); Remote; USD 150,000 - 200,000; Full time

Job summary

Alura Workforce Solutions is seeking a Physician Reviewer to provide clinical decision-making oversight and support quality management across Health Plan departments. The ideal candidate will have extensive medical expertise, strong communication skills, and experience in clinical leadership. This remote position requires residency in California, emphasizing commitment to regulatory compliance and quality assurance.

Qualifications

• Five or more years of post-residency experience in a recognized medical specialty.
• Medical leadership experience is preferred.
• Active, unrestricted Physician's Certificate issued by the California Medical Board.

Responsibilities

• Provide support in clinical decision-making oversight and physician-level guidance.
• Review medical service requests and make determinations based on medical necessity.
• Support Medical Directors in providing medical direction and guidance.

Skills

Medical expertise

Clinical judgment

Communication skills

Risk management

Education

Doctor of Medicine

Certification by American Specialty Boards

Tools

Microsoft Office

Job description

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

Schedule : Monday - Saturday, - hrs week.

Assignment Length : Up to , 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 regulatory requirements set forth by various government agencies. The Physician Reviewer performs Medical Review activities and supports the Health Plan Medical Director. Responsibilities include making determinations, communicating medical necessity reviews, and supporting the Medical Director(s) as needed or requested.

Commitment to Quality :

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

Key Responsibilities

• Provide medical expertise, clinical judgment, and accepted medical standards in clinical decisions to ensure services are medically necessary, appropriate, and meet recognized standards.
• Review routine and urgent medical service requests based on medical necessity, including prior authorizations, inpatient care, DRG reviews, quality reviews, and grievances. Complete determinations prior to due dates in the health plan's care management system, including weekends and holidays, in accordance with Medicare and Medi-Cal regulations. Document all services in the clinical care management systems.
• Review cases and provide support to the Medical Director as needed, including policy review, committee participation, or ICT support. Collaborate with nurses and non-clinical staff for medical case reviews.
• Conduct peer-to-peer discussions regarding determinations when applicable.
• Participate in training sessions to familiarize with Health Plan's clinical care management systems.
• Provide direction on current clinical practices for health services.
• Participate in health quality improvement efforts, managing resources to ensure efficient healthcare delivery and support strategic goals.
• Assist Medical Directors in providing medical direction and guidance in inpatient and outpatient authorizations, grievances, quality reviews, and care coordination with external agencies. Participate in interdisciplinary care teams and case conferences.
• Support health plan committees with clinical input.
• Perform other duties as required under the guidance of the Medical Director to ensure successful health plan operations.

Responsibilities

Education & Requirements

• Five or more years of post-residency experience in a recognized medical specialty required. Experience as a Medical Director for an IPA, medical group, or HMO is highly desirable. Utilization management experience is a plus. Primary Care Physician in internal medicine, family practice, or pediatrics preferred.
• At least one year of medical leadership experience preferred.
• Doctor of Medicine or equivalent from an accredited institution required.
• Certification by one of the American Specialty Boards required.
• Possession of an active, unrestricted Physician's and Surgeon's Certificate issued by the California Medical Board or a Clinical Psychologist License issued by the California Board of Psychology required. Physicians certified in other states may be employed prior to California certification if an application is filed before appointment. Primary Care Physician in internal medicine, family practice, or pediatrics preferred.

Key Qualifications

• Strong knowledge of CMS and medical regulations, quality assessment, utilization review, peer review, credentialing, and risk management.
• Understanding of managed care policies, principles of supervision, and medical sciences.
• Proficiency with Microsoft Office applications; strong communication skills.
• Ability to foster positive working relationships.
• Physical ability to stand, walk, sit, handle objects, reach, climb, balance, stoop, kneel, crouch, crawl, talk, hear, and taste or smell occasionally.
• Occasional lifting up to pounds.
• Specific vision abilities include close, distance, color, peripheral, depth perception, and focus adjustment.

Telecommute (All positions approved for telecommute or hybrid work may periodically require reporting to the main campus for meetings or other business needs as determined by leadership.)