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.