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Physician Reviewer (Internal / Family Medicine)

Bluebird Staffing

Physician Reviewer (Internal / Family Medicine)

San Diego, CA
Full Time
Paid
  • Responsibilities

     

    Location: San Diego, CA

    Hours: 8am – 5pm, weekends as needed

    Salary: $157k up to $249k (depending on experience)

    Relocation Assistance: Possible for the right candidate

    Requirements:

    • Certification: Board Certified in Internal Medicine or Family Medicine
    • Degree: MD Degree (not DO)
    • State License: CA state license in good standing or CA license must be in progress prior to start date
    • Experience: 7+ years of experience required
    • Five years’ experience as a practicing primary care physician with knowledge of managed care and the process for prior authorization review
    • Knowledge of physician social and political behavior and managed care philosophy
    • Effective communication skills
    • Ability to work collaboratively with medical leadership and administration, medical staff, nurses, and hospital administration.

    Job Summary:

    • The Physician Reviewer will perform all reasonably necessary functions to ensure quality of care and appropriate utilization in the most cost-effective, appropriate and professional manner, which meets the expressed needs of patients and professional colleagues.
    • The Physician Reviewer will be a part of the Health Services Department. This department is comprised of areas of Medical Management, Provider Relations/Network Support, Quality Improvement and Pharmacy.
    • Provide clinical determinations based on evidence-based criteria and internal guidelines and policies, while utilizing your clinical acumen.
    • Clearly and accurately document all communication and decision-making with workflow tools, ensuring a member could easily reference and understand your decision.
    • Use correct templates for documenting decisions during case review.
    • Meet the appropriate turn-around times for clinical reviews.
    • Receive and review escalated reviews (either initial denial or internal / first level appeal).
    • Conduct timely peer-to-peer discussions with treating providers to clarify clinical information and to explain review outcome decisions, including feedback on alternate treatment based on medical necessity criteria and evidence-based research.
    • Demonstrate the highest level of professionalism, accountability, and service in your interactions with teammates, providers, and members.