Physician Reviewer

AltaMed•Montebello, CA

About The Position

The Physician Reviewer, Medical Management, routinely reviews authorization requests across all lines of business using applicable national and state health plans and nationally recognized guidelines to guide referral processing. The reviewer approves authorizations within the responsibilities in the AltaMed Authorization Matrix and applicable training and licensing restrictions, and processes authorization denials using standard language based on the relevant guideline hierarchy. The reviewer posts recommendations in the authorization platform to inform Medical Director workflows. The role reviews and makes recommendations on retrospective claims reviews involving outpatient and inpatient authorizations and emergency room claims. It may also support ad hoc projects and analyses related to high-cost utilization, unmanaged care, inappropriate utilization, billing practices, and budget or financial reporting. The reviewer identifies high-risk populations through provider or clinic referrals, utilization management referrals, disease registry reporting, and patient self-referral, and refers patients to appropriate case management programs. With approval from the Medical Director of Pediatric Utilization Management, the reviewer may provide oversight, guidance, and training to utilization management nurse reviewers and other UM staff. The position provides case management for hospitalized patients and those who may need ambulatory case management, and works with an interdisciplinary care team to coordinate services such as social work, mental health counseling, psychosocial support, in-home support, legal services, skilled nursing, and home health.

Requirements

MD or DO.
Completion of a physician training program.
Board certification is preferred.
Graduation from an accredited medical training program.
Valid BLS certification or higher, following American Heart Association or American Red Cross guidelines.

Nice To Haves

Board certification.

Responsibilities

Review authorization requests for all lines of business using applicable health plans and recognized guidelines.
Approve authorizations within delegated responsibilities and applicable training and licensing restrictions.
Process authorization denials using standard denial language and post recommendations in the authorization platform for Medical Director workflows.
Review and make recommendations on retrospective claims reviews for outpatient and inpatient authorizations and emergency room claims.
Participate in ad hoc projects and analyses involving utilization, billing practices, and budget or financial reporting.
Identify high-risk populations and refer patients to appropriate case management programs.
With Medical Director approval, provide oversight, guidance, and training to UM nurse reviewers and other UM staff, where applicable.
Provide case management to hospitalized patients and patients who may need ambulatory case management.
Coordinate care as part of an interdisciplinary team with social work, mental health counseling, psychosocial support, in-home support, legal services, skilled nursing, and home health.