Job Description
Job Title: Physician Peer Reviewer (MD) Salary Expectations -$240K-$277K
Work Location: Remote
- Candidate must be licensed in any of these four states (MT, ID, WA, or OR)
- Candidate must reside in one of the following states - NV, KS, GA, CO, MO, MN, OR, ID, and MT
Shift/Schedule:
- Full Time Hours between 8am-5pm PST
Job Type /Contract Duration: 3-6 month contract
Discipline: Healthcare Physicians
General Overview: We are seeking a Physician Peer Reviewer (MD) to provide expert medical review and support for utilization management, claims adjudication, and appeals. This remote role requires an unrestricted medical license in MT, ID, WA, or OR and residence in one of the following states: NV, KS, GA, CO, MO, MN, OR, ID, MT, or WA.
In this role, you will collaborate with Care Management, Quality, Utilization Management, and Population Health teams, serving as a clinical expert in reviewing pre-authorizations, claims, appeals, and case management decisions. You will also provide input on credentialing, pharmacy and therapeutics policies, and medical necessity determinations while ensuring alignment with industry best practices and regulatory requirements.
Essential Functions: - Interface with Care Management, Clinical, Quality, and Utilization Management departments and activities.
- As assigned, participate in relevant Manager/Supervisor meetings including meetings related to Population health, Provider Network, Quality, Risk, and Health Services Teams, as convened by Chief Medical Officer (CMO) or designee.
- As appropriate, function as liaison between the local provider community and clinical enterprises to facilitate coordination and the execution of work.
- As appropriate, review and manage appeals, and lend expertise to the preparation of cases for further external review, including OHA hearings.
- As appropriate, provide expertise and medical interpretation with respect to claims adjudication, contract language, disputes and appeals, policy drafts, and care management issues.
- As appropriate, oversee the management of appropriate care and case management related to acute, catastrophic, and long-term cases.
- As appropriate, review pre-authorizations, claims, and other cases involving pre- or post-service requests for coverage.
- As appropriate, conduct other utilization review activities (e.g., lengths of stay, appropriateness of service, intensity of service, medical necessity, and experimental/investigational services) on a prospective, concurrent, or retrospective basis.
- As assigned, assist with credentialing review of providers and the resolution of issues brought forward by credentialing staff. Help to staff the Credentialing Committee, prepare agendas, present practitioner issues, develop policies, and oversee actions of the committee.
- As assigned, assist with Pharmacy and Therapeutics Committee functions, as defined by the Pharmacy Director.
- Assist the Chief Medical Officer or his designee, as requested, including periodic involvement with providers, and members, management, and other functions or committees as needed.
- Collaborate with local providers and Medical Directors to establish guidelines, policies, criteria and procedures for review and determination related to clinical practices, claims, care coordination, reimbursement, provider credentialing, and quality management.
- As assigned, research new technologies, new medications, and other evolving healthcare products and services to help determine a standard of care and standard of coverage. Assist with drafting and revision of policies relating to such issues.
- Provide visibility and maintain positive physician relationships as a representative of, in the local and regional medical community.
- Provide clinical expertise to the Quality / Risk Department, including QIMs, NCQA, HEDIS, and CAHPS Programs.
Job Requirements - Board certification recognized by the American Board of Medical Specialties (ABMS) is preferred.
- Doctor of Medicine (MD or DO) with an unrestricted license to practice medicine in any of the four states (MT, ID, WA, OR), or be willing to apply for state licensure in one of these four states.
- MD or DO required. Minimum of three (3) years of experience as an Assistant Medical Director or Medical Officer of a health insurance plan, or related experience required.
- Experience in an integrated healthcare system a plus
- Significant senior management policy and decision-making experience, including developing and implementing management best practices preferred.
- Comprehensive knowledge of business principles and techniques of administration, organization, and management to include an in-depth understanding of the key business issues that exist in the healthcare industry. These include, but are not limited to quality improvement including, Lean methodology, healthcare economics, personnel administration, financial and cost analysis, trends in the healthcare industry.
- Excellent understanding of all areas of medical conditions, treatment, and care.
- Excellent understanding of the insurance industry and risk factors, and how they relate to the organization.
- Remain current in the medical field. Basic computer skills required.
- In-depth knowledge of local clinical communities, along with in-depth knowledge of Oregon Health Plan preferred.
- Ability to read and comprehend Spanish a plus.
Benefits Once you have been a Full Time contract employee of Medix for 30 days, you become eligible for our Benefits Program. Should you elect to enroll, there are three levels of medical coverage to choose from, supplemental dental plans and term plans as well as the option to enroll your spouse and/or children. You can select the best combination that best suits your needs.
As a contract employee with Medix, you can choose to enroll in our Benefits Program during your eligibility period and enjoy:
- 401(k) Retirement Plan
- Paid time off benefits available
- Continued Education Reimbursement
- Full Benefits free of cost
- Doctor visits with inexpensive co-pay
- Limited Outpatient Care
- Limited Accident Coverage
- Prescription Programs
- Dental Plan
- Vision Discount Program
- Term Life Insurance Plans
For California Applicants:
We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO) , and the California Fair Chance Act (CFCA).
This position is subject to a background check based on its job duties, which may include patient care, working with vulnerable populations, access to financial and confidential information, driving, working with heavy machinery, or working in a warehouse or laboratory environment. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.
Job Tags
Full time, Contract work, Local area, Shift work,