Physician Advisor (Utilization Management Md)

Position Summary:

The Physician Advisor works with Health Plan Medical Director, Utilization Management team, Appeals and Grievances team and Claims department to ensure medically necessary use of services, manage total cost of care and ensure that benefits are administered appropriately. Through remote access to our web-based Portal, Physician Advisor will complete clinical reviews for medical necessity, maintain compliance, adjudicate appeals and grievances from members and providers.

General Duties/Responsibilities (May include but are not limited to):

• Perform utilization reviews in compliance with Medicare NCD & LCD, Milliman guidelines, evidence based guidelines and health plan guidelines.
• Render medical necessity coverage determination for prior authorization, concurrent review and retrospective reviews.
• Adjudicate medically related grievances and appeals that flow through member grievance and appeals process.
• Review medically related potential quality of care issues.
• Document all communication and decision making clearly within health plan portal.
• Ensure appropriate service utilization and benefit administration by monitoring over- and underutilization
• Act as a liaison between the medical staff, utilization review and third party services to effectively promote the appropriate levels of medical care.
• Serve as medical expertise for Utilization Management; reviews and evaluates cases with review nurses.
• Serve as a physician member of the Utilization Management team.
• Expected to perform peer to peer discussion as necessary to clarify clinical information, explain review outcome decisions, discuss medical necessity and any other clinical discussions.
• Expected to perform all reviews in accordance to CMS compliance standard for turn around time.
• Participate in inter-rater reliability exercises.
• Participate in relevant health plan committees, including but not limited to credentialing, quality, UM meetings, staff meetings and joint work group meetings with delegated groups as directed by Medical Director.
• Assist with creating and developing departmental policies as needed.
• Assist with regulatory requirements including external and internal audits and monitoring.
• Collaborates closely and provide assistance to Health Plan Medical Director
• This position reports directly to Health Plan Medical Director.

Supervisory Responsibilities:

N/A

Minimum Requirements:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and/or ability required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Minimum experience:

• Minimum 5 years of clinical experience.
• MD or DO from a fully accredited university and residency program.
• 2-3 years experience in health plan, medical group or hospital Utilization Management position involving utilization, appeals/grievance and retrospective review.
• Strong knowledge of medical and CMS regulations.

 Education/Licensure:

• Current, valid and unrestricted California Physician and Surgeon's license with Board certification in one of the American Board of Medical Specialties (internal medicine preferred).
• Must be willing and eligible to apply for license in the following states and all future states that Health plan expands into: Arizona, Nevada, Florida, Texas and North Carolina. (licensure expenses will be paid for by company)
• Any Utilization Management related certification is a plus.

 Other:

• Ability to build rapport with medical staff and management leadership to obtain necessary approvals of new strategies for Utilization Management.
• Knowledge of current medical literature, research methodology, healthcare delivery systems, healthcare financial/reimbursement issues, and medical staff organizations.
• Dedication to the delivery of high-quality, cost-effective, efficient patient care services
• Excellent communication skills
• Must have great attention to detail and discipline to complete workload within turn around time.
• Mon- Fri 8- 5PM with minimal weekend/holidays requirements.
• Remote position with occasional in-office meetings.

 Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Essential Physical Functions:

• The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 

• While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
• The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.