Physician Reviewer, Medical Management at AltaMed Health Services in Montebello, California

Job Description:

Position Title: Physician Reviewer, Medical Management

Location: Montebello, CA 90640

Post Date: Posted Yesterday

Description:

Grow Healthy

If you are as passionate about helping those in need as you are about growing your career, consider AltaMed. At AltaMed, your passion for helping others isn’t just welcomed – it’s nurtured, celebrated, and promoted, allowing you to grow while making a meaningful difference. We don’t just serve our communities; we are an integral part of them. By raising the expectations of what a community clinic can deliver, we demonstrate our belief that quality care is for everyone. Our commitment to providing exceptional care, despite any challenges, goes beyond just a job; it’s a calling that drives us forward every day.

Job Overview

The Physician Reviewer of Utilization Management will provide routine review of authorization requests from all lines of business using respective national/state, health plan, nationally recognized guidelines where appropriate to provide guidance for processing of referrals to Medical Director staff and to UM staff. Physician Reviewers may approve authorizations per delegation responsibilities in AltaMed Authorization Matrix and where applicable per restrictions of their training and licensing. Physician Reviewers will process Denials of authorizations using standard denial language noted from above hierarchy of guidelines and post recommendations in the authorization platform to inform Medical Director workflow. Physician Reviewers may review and make recommendations on retro claims reviews for outpatient authorization, inpatient authorizations, and Emergency Room claims. Physician Reviewer may be involved in ad hoc projects and analysis of high cost utilization areas, unmanaged care, inappropriate utilization, inappropriate billing practices, and budgeting/finances reporting. May be responsible for identifying high risk population via provider/clinic referral, utilization management referral, disease registry reporting mechanisms and patient self-referral and will refer high risk patients to appropriate case management program per AltaMed Case Management Policy. With the approval of the Medical Director of Medical Management, Physician Reviewers may provide oversight, guidance, and training sessions to UM nurse reviewers and other UM staff where applicable. This position will provide case management to patients who are admitted to the hospital and those patients who may need to be enrolled in ambulatory case management. The Physician Reviewer may work as part of an interdisciplinary care team participating in the coordination of care with social work and mental health counseling, psycho-social support services, in-home support, legal services, skilled nursing, home health, etc. Effectively collaborates with the hospitalist, the hospital nursing personnel, with members of the interdisciplinary care team and with the physicians in the clinic.

Minimum Requirements

• MD/DO, Physician Training Program completed, Board Certified Preferred

• Graduation from an accredited medical training program.

• CA Physician License in good standing

• 3+ years of Health Plan or IPA experience doing UM Authorization Reviews

• 3+ years of experience decisioning cases using Medi-Cal and Medicare guidelines

• 3+ years of experience using InterQual or MCG

• Board Certified in Internal Medicine, Family Practice, or Pediatrics

Salary Range

• $208,000.00 - $282,963.20 annually

Compensation Disclaimer

Actual salary offers are considered by various factors, including budget, experience, skills, education, licensure and certifications, and other business considerations. The range is subject to change. AltaMed is committed to ensuring a fair and competitive compensation package that reflects the candidate's value and the role's strategic importance within the organization. This role may also qualify for discretionary bonuses or incentives.

Benefits & Career Development

• Medical, Dental and Vision insurance
• 403(b) Retirement savings plans with employer matching contributions
• Flexible Spending Accounts
• Commuter Flexible Spending
• Career Advancement & Development opportunities
• Paid Time Off & Holidays
• Paid CME Days
• Malpractice insurance and tail coverage
• Tuition Reimbursement Program
• Corporate Employee Discounts
• Employee Referral Bonus Program
• Pet Care Insurance

Job Advertisement & Application Compliance Statement

AltaMed Health Services Corp. will consider qualified applicants with criminal history pursuant to the California Fair Chance Act and City of Los Angeles Fair Chance Ordinance for Employers. You do not need to disclose your criminal history or participate in a background check until a conditional job offer is made to you. After making a conditional offer and running a background check, if AltaMed Health Service Corp. is concerned about a conviction directly related to the job, you will be given a chance to explain the circumstances surrounding the conviction, provide mitigating evidence, or challenge the accuracy of the background report.

Remote Type: In Person


About US: As the nation’s largest Federally Qualified Health Center (FQHC), AltaMed is at the forefront of providing affordable, high-quality health care to underserved communities in Los Angeles and Orange Counties. At AltaMed, you will have the opportunity to work with a diverse team of dedicated professionals who are passionate about making a difference and supporting our community of over 400,000 patients.

Learn About AltaMed: Click Here

AltaMed Health Services Corporation is committed to providing equal employment opportunities for all qualified individuals. We strictly prohibit discrimination in employment based on race, color, creed, religion, marital status, sexual orientation, registered domestic partner status, sex, gender, gender identity or expression, ancestry, national origin, age, medical condition, physical or mental disability, military or protected veteran status, pregnancy or perceived pregnancy, childbirth, breastfeeding or related medical conditions, genetic information, or any other characteristic protected by local, state, or federal law, ordinance, or regulation.

We are committed to promoting equality and inclusivity beyond our recruitment and hiring processes. We aim to create a respectful, valued, and inclusive workplace through training, advancement opportunities, and access to resources and support. We focus on fostering a diverse workforce because it enriches our organization and improves our ability to effectively serve our clients and community. We encourage individuals from all backgrounds to apply and join us in our mission to create a positive impact.

Equal employment opportunity, including veterans and individuals with disabilities.

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