[Hiring] Physician Reviewer @AltaMed

Role Description

The Physician Reviewer, Medical Management, provides a routine review of authorization requests from all lines of business using respective national/state health plans and nationally recognized guidelines where appropriate, to guide the processing of referrals.

• The Physician Reviewer approves authorizations per delegation responsibilities in the AltaMed Authorization Matrix and, where applicable, per their training and licensing restrictions.
• Processes denials of authorizations using standard denial language noted from the hierarchy of guidelines and posts recommendations in the authorization platform to inform the Medical Director workflow.
• Reviews and makes recommendations on retro claims reviews for outpatient authorization, inpatient authorizations, and Emergency Room claims.
• May be involved in ad hoc projects and analysis of high-cost utilization areas, unmanaged care, inappropriate utilization, billing practices, and budgeting/finances reporting.
• Responsible for identifying high-risk populations 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 programs.
• Provides oversight, guidance, and training sessions to UM nurse reviewers and other UM staff, where applicable, with the approval of the Medical Director of Pediatric Utilization Management.
• Provides case management to patients admitted to the hospital and those who may need to be enrolled in ambulatory case management.
• Works 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.

Qualifications

• MD/DO, Physician Training Program completed, Board Certified Preferred.
• Graduation from an accredited medical training program.
• A minimum requirement of a valid BLS certification or higher, following the American Heart Association (AHA) or the American Red Cross guidelines.

Benefits

• 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.

Company Description

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.