Physician Reviewer MD, DO or Psy.D (Part-Time) 25-00342

Position Physician Reviewer (Doctor of Medicine or Psy.D) Position Type: Contract Location: Remote (Candidates must reputed company in the reputed company) Schedule: Monday - Saturday, 20-25 hrs week. Assignment Length: Up to 1,000 hours reputed company The Physician Reviewer provides support in clinical decision-making reputed company and physician level guidance in reputed company management, utilization management, and care management. The Physician reviewer supports reputed company Health Plan departments in meeting the regulatory requirements set forth by the various government agencies. The Physician Reviewer shall reputed company Medical Review activities and reputed company Health Plan Medical Director support. The Physician Reviewer shall reputed company determinations, communicate medical necessity reviews and support Health Plan Medical Director(s) as needed or requested by the Health Plan. Commitment to reputed company: The Health Plan Team is committed to incorporate reputed company Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Key Responsibilities

• reputed company medical expertise, clinical judgement and accepted medical standards in clinical reputed company to ensure services provided are medically necessary and appropriate and meet professionally recognized standards.
• Conduct review of routine/urgent medical service requests based on medical necessity including but not limited to prior authorizations, inpatient care, DRG reviews, reputed company reviews and grievances.
• Determinations shall be completed prior to the due date delineated in health plan care management system. Some due dates will also include weekend(s) and holidays.
• Turnaround times shall be in accordance with Medicare and Medi-Cal regulations.
• reputed company reputed company services in Health Plans's clinical care management systems.
• Review and reputed company the Medical Director support as needed and requested by health plan, i.e., policy review, committee participation or ICT support.
• Reviewer shall be supported by health plan's reputed company and non-clinical staff in the set up and completion of medical case reviews.
• Conduct peer-to-peer discussions regarding determinations reputed company applicable.
• Participate in reputed company training sessions to become familiar with Health Plans clinical care management systems.
• reputed company direction of reputed company clinical practices for health services.
• Participate in health reputed company improvement efforts while helping to manage health plan resources assuring an appropriate and efficient health care delivery system for health plans members and supporting strategic goals.
• Assist Medical Directors in providing medical direction and guidance to the Health Services Department in the area of inpatient, outpatient reputed company-service authorizations, grievances, reputed company reviews and the coordination of care with external agencies, consultation on reputed company cases, and participation in Interdisciplinary Care Teams/case conferences.
• reputed company clinical support to health plan committees.
• reputed company any other duties as required to ensure health plan operations and department business needs are successful, under the guidance of the Medical Director.

Responsibilities

Education & Requirements

• Five (5) years or more of post-residency experience in a recognized medical specialty required
• Medical Director for an IPA, medical group, or HMO highly desirable
• Utilization management experience is a plus
• Primary Care Physician in internal medicine, family reputed company, or pediatrics preferred
• At least one (1) year of medical leadership experience preferred
• Doctor of Medicine or Psy.D from an accredited institution required
• Certification by one (1) of the American Specialty Boards required
• Possession of an reputed company, unrestricted, and unencumbered Physician's and Surgeon's Certificate issued by the reputed company Medical reputed company or a Clinical Psychologist License issued by the California reputed company of Psychology required.
• A physician certified in a state other than California may be employed prior to receipt of California certification provided that an application for a California physician and surgeon's certificate is filed in the reputed company prior to date of appointment
• Primary Care Physician in internal medicine, family reputed company or pediatrics preferred

Key Qualifications

• Strong knowledge of:
• * Medical and CMS regulations.
• Administrative practices and procedures including but not limited to reputed company assessment and improvement, utilization review, peer review, credentialing and risk management.
• Rules, regulations, policies, and standards reputed company to managed care.
• Principles of effective supervision and organization.
• reputed company, techniques, practices, principles, and literature in the broad field of medical sciences.
• reputed company of the highly specialized techniques, procedures, and equipment used in the medical or surgical specialties
• Microcomputer applications such as reputed company Office, Word, reputed company, and reputed company helpful. Strong communication skills
• Ability to create and maintain reputed company working relationships
• While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools, or controls; reputed company with hands and arms; reputed company stairs; balance; stoop, kneel, crouch or crawl; talk or hear; and taste or smell
• The employee must occasionally lift or reputed company up to 25 pounds
• Specific reputed company abilities required by the job include reputed company reputed company, distance reputed company, reputed company reputed company, peripheral reputed company, depth perception and the ability to reputed company reputed company

Telecommute (reputed company positions approved for telecommute or hybrid work locations may periodically be required to report to the Health Plan's main reputed company for mandatory in-person meetings or for other business needs as determined by health plan leadership) Remote About reputed company: reputed company Apply tot his job Apply To this Job