Utilization Management Physician

Northwest Permanente; Portland (OR); Sur place; USD 180 000 - 320 000; Plein temps

Avantages offerts par ce poste

Pension plan

Comprehensive benefits

Paid education leave

Résumé du poste

Northwest Permanente is seeking a full-time Utilization Management Physician to determine medical necessity for Kaiser Permanente members, applying clinical judgment and established guidelines. The role involves administrative responsibilities within a physician-led group in Oregon, with emphasis on policy adherence and high-stakes decision-making.

The position requires board certification, state licensure in Oregon and Washington, and substantial experience in clinical practice plus utilization

Qualifications

• Board-certified MD or DO required.
• Current unrestricted medical licensure in Oregon and Washington.
• Minimum five (5) years of clinical practice.
• Minimum two (2) years of utilization management experience.

Responsabilités

• Conduct daily utilization management medical necessity reviews and coverage assessments based on member information, plan benefits, and applicable policies.
• Participate in over-the-phone hearings with Administrative Law Judge for adverse determinations.
• Provide initial training and ongoing education to utilization management staff.
• Maintain knowledge of regulatory requirements and participate in inter-rater reliability sessions.
• Conduct pre-registration calls to obtain authorizations from non-Kaiser Permanente insurers for imaging and procedures.

Formation

Board-certified MD or DO

Description du poste

Overview

The Utilization Management Physician makes coverage determinations about requested services included in Kaiser Permanente members’ benefits packages by exercising clinical judgment, supported by established guidelines and key criteria to determine medical necessity. This position is a full-time administrative physician role.

Overview

The Utilization Management Physician makes coverage determinations about requested services included in Kaiser Permanente members’ benefits packages by exercising clinical judgment, supported by established guidelines and key criteria to determine medical necessity. This position is a full-time administrative physician role.

Major Responsibilities

• Conducts daily utilization management medical necessity reviews and coverage reviews based on individual member’s clinical information, plan benefits, national, state, CMS and proprietary coverage policies, evidence-based references and/or expert opinion and renders determinations including authorizations and adverse determinations.


• Participates in over-the-phone hearings with Administrative Law Judge regarding adverse determinations for members with Oregon Health Plan coverage. Conducts peer to peer calls, when requested, on adverse determinations.


• Provides initial training and ongoing education to, and in collaboration with, utilization management physicians, nurses and support staff.


• Maintains ongoing knowledge of regulatory requirements relevant to utilization management and participates in inter-rater reliability sessions.


• Conducts pre-registration calls to obtain authorizations from non-Kaiser Permanente insurance companies for imaging and procedures to be performed at Kaiser Permanente.

Minimum Education, Licenses And Experience

• Board certified MD or DO. Current unrestricted medical licensure in Oregon and Washingon.


• Minimum five (5) years of clinical practice.


• Minimum two (2) years of utilization management experience.

Our Northwest Permanente Physicians Enjoy

• Generous automatic employer-funded pension and retirement contributions totaling 21% of eligible clinician earnings with additional employee contribution optional.


• Competitive compensation that is not based on fee-for-service model.


• Pathway for physicians to become shareholders of Northwest Permanente.


• Paid annual education leave + annual education allowance.


• Comprehensive benefits including largely employer-funded medical, dental insurance premiums, life insurance, and paid leave.

About Northwest Permanente

Northwest Permanente (NWP) is the largest multispecialty medical group in Oregon and southwest Washington with more than 1,300 physicians and 300 administrative professionals caring for over 600,000 Kaiser Permanente members. Northwest Permanente is owned and led by physicians who earn competitive salaries, without income based on providing individual services. Our medical group comprises board-certified physicians across 50+ specialties.

Equal Opportunity Employer

Northwest Permanente is an equal opportunity employer committed to fair, respectful, and inclusive workplaces. Applicants will be considered for employment without regard to race, religion, sex, age, national origin, disability, veteran status, or any other protected characteristic or status.