Physician Reviewer

AltaMed•Montebello, CA

3d•$248,923 - $311,153

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 according to the AltaMed Authorization Matrix and, where applicable, training and licensing restrictions. They process authorization denials using standard language based on the relevant guidelines and enter recommendations in the authorization platform for the Medical Director workflow. The role reviews and makes recommendations on retroactive claims reviews involving outpatient and inpatient authorizations and Emergency Room claims. It may also involve ad hoc projects and analysis of high-cost utilization, unmanaged or inappropriate care, billing practices, and budget or financial reporting. The Physician Reviewer identifies high-risk populations through provider or clinic referrals, utilization management referrals, disease registry reporting, and patient self-referral, then 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 UM nurse reviewers and other UM staff. The role provides case management to hospitalized patients and others who may need ambulatory case management, and participates in interdisciplinary care coordination with social work, mental health counseling, psychosocial support, in-home support, legal services, skilled nursing, home health, and other services.

Requirements

MD or DO.
Completion of a physician training program.
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 preferred.

Responsibilities

Review authorization requests across all lines of business using applicable health plans and recognized guidelines.
Approve authorizations according to the AltaMed Authorization Matrix and applicable training and licensing restrictions.
Process authorization denials using standard denial language and post recommendations in the authorization platform for the Medical Director workflow.
Review and make recommendations on retroactive claims reviews for outpatient and inpatient authorizations and Emergency Room claims.
Participate in ad hoc projects and analyses concerning high-cost utilization, unmanaged care, inappropriate utilization, billing practices, and budgeting or financial reporting.
Identify high-risk populations through referrals, disease registry reporting, and patient self-referral, and refer patients to appropriate case management programs.
With approval from the Medical Director of Pediatric Utilization Management, 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, home health, and other services.