Physician Reviewer
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Job Description
Physician Reviewer guiding medical authorizations, utilization reviews, and case management. Supporting AltaMed’s community clinic mission through interdisciplinary patient care coordination.
Responsibilities:
- Conduct routine reviews of authorization requests across all lines of business using applicable national/state health plans and recognized guidelines
- Approve authorizations according to delegation responsibilities, the AltaMed Authorization Matrix, training, and licensing restrictions
- Process authorization denials using standard denial language and post recommendations in the authorization platform
- Review and make recommendations on retro claims for outpatient authorizations, inpatient authorizations, and emergency room claims
- Participate in ad hoc projects and analyze high-cost utilization, unmanaged care, inappropriate utilization, billing practices, and budgeting/financial reporting
- Identify high-risk populations and refer patients to appropriate case management programs
- Provide oversight, guidance, and training to UM nurse reviewers and other UM staff when applicable
- Provide case management to hospitalized patients and patients needing ambulatory case management
- Participate in interdisciplinary care coordination with social work, mental health counseling, psychosocial support, in-home support, legal services, skilled nursing, and home health teams
Requirements:
- MD/DO
- Physician Training Program completed
- Graduation from an accredited medical training program
- Valid BLS certification or higher, following American Heart Association (AHA) or American Red Cross guidelines
- Board Certified preferred
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
- Discretionary bonuses or incentives may apply
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