Offer summary

Qualifications:

MD/DO degree with completion of a Physician Training Program., Board Certification preferred., Graduation from an accredited medical training program is required., Strong understanding of medical guidelines and authorization processes..

Key responsabilities:

Review authorization requests from various lines of business using established guidelines.

Approve or deny authorizations based on delegation responsibilities and training.

Identify high-risk populations and refer them to appropriate case management programs.

Provide oversight and training to UM nurse reviewers and participate in interdisciplinary care coordination.

Job 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, 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. The Physician Reviewer, Medical Management processes denials of authorizations using standard denial language noted from the above hierarchy of guidelines and posts recommendations in the authorization platform to inform the Medical Director workflow. Physician Reviewers of Medical Management review and make recommendations on retro claims reviews for outpatient authorization, inpatient authorizations, and Emergency Room claims. Physician Reviewer, Medical Management may be involved in ad hoc projects and analysis of high-cost utilization areas, unmanaged care, inappropriate utilization, billing practices, and budgeting/finances reporting. The Physician Reviewer, Medical Management is 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. With the approval of the Medical Director of Pediatric Utilization Management, Physician Reviewer, Medical Management provides oversight, guidance, and training sessions to UM nurse reviewers and other UM staff where applicable. This position will provide case management to patients admitted to the hospital and those who may need to be enrolled in ambulatory case management. The Physician Reviewer, Medical 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.

 Minimum Requirements

MD/DO, Physician Training Program completed, Board Certified Preferred
Graduation from an accredited medical training program.

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.

Required profile