Remote Medicare Advantage UM Physician Leader

SCAN Group; Long Beach (CA); A distancia; USD 207.000 - 276.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Excellent 401(k) retirement plan

Mostly remote work with occasional in‑

Descripción de la vacante

SCAN Group in Long Beach, CA seeks a Medicare Advantage Utilization Management Physician to provide physician-level determinations for prior authorization, concurrent reviews, and appeals. The ideal candidate will have CA residency, Medicare UM experience, and a current MD/DO license.

The role emphasizes timely, evidence-based decisions, peer discussions, and leadership in mentoring RN reviewers and intake staff to uphold NCQA/URAC standards and CMS requirements.

Formación

• Graduate of an accredited medical school required.
• Board certification in good standing in a relevant specialty (e.g., Internal Medicine, Family Medicine, Emergency Medicine).
• Minimum of 5 years of active clinical practice experience.
• Minimum of 2-3 years of utilization management experience in a health plan environment.
• Working knowledge of MCg/NCQA/URAC/CMS requirements and Medicare decisioning.”],
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• The You Will section outlines physician-level medical necessity review for prior authorization, concurrent and retrospective reviews; timely determinations; peer-to-peer discussions; and involvement in first-level appeals and potential expert peer reviews.;
• Provide clinical guidance and mentorship to RN reviewers and intake staff; escalate complex cases.
• Ensure UM decisions meet NCQA/URAC accreditation standards and regulatory requirements; identify patterns of inappropriate utilization and quality concerns; escalate as appropriate.
• Communicate with providers regarding review determinations and educate on UM policies to reduce denials.

Responsabilidades

• Perform physician-level medical necessity review of prior authorization requests, concurrent (inpatient) reviews, and retrospective reviews referred by RN reviewers when clinical criteria are not clearly met.
• Render timely determinations consistent with Medicare guidelines, MCg, evidence-based guidelines, plan policy, standard of care, and regulatory turnaround-time requirements.
• Conduct peer-to-peer discussions with attending physicians and treating providers prior to issuing an adverse determination; document clinical rationale clearly and defensibly.
• Serve as a physician reviewer for first-level appeals; refer cases to independent or specialty peer review and participate in ALJ hearings as required.
• Maintain availability for urgent/expedited reviews within required turnaround windows.
• Provide clinical guidance and mentorship to RN reviewers and intake staff; serve as a point of escalation for complex or ambiguous cases.
• Ensure UM decisions and documentation meet NCQA/URAC accreditation standards and applicable state/federal regulatory requirements; identify and remediate patterns of inappropriate utilization and quality concerns.
• Communicate professionally with network providers regarding review determinations and educate providers on UM policies to reduce avoidable denials.

Conocimientos

Clinical decision making

Peer-to-peer discussions

Regulatory knowledge

Communication skills

Mentorship/leadership

Educación

MD/DO

Descripción del empleo

SCAN Group in Long Beach, CA seeks a Medicare Advantage Utilization Management Physician to provide physician-level determinations for prior authorization, concurrent reviews, and appeals. The ideal candidate will have CA residency, Medicare UM experience, and a current MD/DO license.

The role emphasizes timely, evidence-based decisions, peer discussions, and leadership in mentoring RN reviewers and intake staff to uphold NCQA/URAC standards and CMS requirements.