Physician Reviewer

Grow HealthyIf 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 OverviewThe 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 PreferredGraduation from an accredited medical training program.A minimum requirement of a valid BLS certification or higher, following the American Heart Association (AHA) or the American Red Cross guidelines.Compensation$248,922.64 - $311,153.30 annuallyCompensation DisclaimerActual 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 DevelopmentMedical, Dental and Vision insurance403(b) Retirement savings plans with employer matching contributionsFlexible Spending AccountsCommuter Flexible SpendingCareer Advancement & Development opportunitiesPaid Time Off & HolidaysPaid CME DaysMalpractice insurance and tail coverageTuition Reimbursement ProgramCorporate Employee DiscountsEmployee Referral Bonus ProgramPet Care InsuranceJob Advertisement & Application Compliance StatementAltaMed 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.SummaryLocation: Montebello, CA 90640Type: Full time