You are applying for a position through Medix, a staffing agency. The actual posting represents a position at one of our clients.

Job Summary

Our client is seeking a skilled Physcian Reviewer who will perform focused real-time case reviews, apply medical judgment and evidence-based guidelines, and participate in quality reviews and interdisciplinary team meetings to improve health care services. The role's primary focus is on home health service reviews, quality improvement, and ensuring compliance with health plan and regulatory requirements.

Key Responsibilities

• Perform focused real-time case reviews by reviewing information in the software systems.
• Apply medical judgment and evidence-based clinical guidelines for medical necessity determinations on pre-service, concurrent, and retrospective claims reviews.
• Review Potential Quality Issues (PQIs).
• Provide quality reviews that align with members' individual needs, medical evidence guidelines, and compliance requirements.
• Identify and document areas of inappropriate resource utilization.
• Participate in inter-rater review.
• Conduct Peer-to-Peer case discussions with various medical stakeholders.
• Maintain positive relationships with both internal and external stakeholders and participate in interdisciplinary team meetings.
• Provide guidance and review activities for home health utilization management and quality improvement activities.
• Provide input on clinical content and assist in developing and reviewing policies.
• Identify clinical quality improvement studies for reducing unwarranted clinical practice variations.
• Participate in regulatory compliance activities related to health services.
• Work collaboratively in a virtual environment with the clinical/medical management team.

Qualifications

• MD or DO license in good standing with no restrictions in the state where UM reviews are conducted.
• Board certification preferable in a primary care specialty (e.g., Internal Medicine, gerontology, Family Medicine, Physical Medicine and Rehabilitation).
• Actively practicing physician with 10+ years of experience.
• Coursework in Health Administration, Health Financing and Insurance is helpful.
• Board Certification through American Board of Medical Specialties.

Experience

• 3+ years of experience conducting UM Authorization and determination reviews in health plan or IPA settings preferred.
• Experience with Peer-to-Peer meetings.
• Experience with Medicare Advantage, Medicare, and Medicaid.
• Minimum 2 years experience with Milliman Care Guidelines or InterQual.

Skills

• Proficiency in computer and technology skills.
• Good communication skills for facilitating provider recommendations and promoting healthcare quality.

Benefits

• Paid Sick Leave (Medix provides paid sick leave according to state and local sick leave ordinances).
• Health Benefits / Dental / Vision (Medix offers 6 different health plans: 3 Major Medical Plans, 2 Fixed Indemnity Plans (Standard and Preferred), and 1 Minimum Essential Coverage (MEC) Plan. Eligibility for health benefits is based on verifying that an average of 30 hours per week during the first 4 weeks of the work assignment has been met. If you meet eligibility requirements and take action to enroll, you will be covered no earlier than 60 days into your assignment, depending on plan selection(s)).
• 401k (Eligible on the first 401k open enrollment date following 6 consecutive months on assignment. 401k Open Enrollment dates are 1/1, 4/1, 7/1, and 10/1).
• Short Term Disability Insurance.
• Term Life Insurance Plan.

Required Employment / Compliance Language

The role adheres to all compliance requirements under state and federal law.

^*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).

Medix Overview:

With over 20 years of experience connecting organizations with highly qualified professionals, Medix is a leading provider of workforce solutions for clients and candidates across the healthcare, scientific, technology, and government industries. Through our core purpose of positively impacting lives, we’re dedicated to creating opportunities for job seekers at some of the nation's top companies. As an award-winning career partner, Medix is committed to helping talent find fulfilling and meaningful work because our mission is to help you achieve yours.

^*As a job position within our Care Management division, a successful completion of a background check may be required as a condition of employment. This requirement is directly related to essential job functions including but not limited to: accessing financial and confidential information, access and handling of patient medical records, providing medical care inside a patient’s residential address, driving, prescription and other drug access and administration, and working with vulnerable populations, such as, minors, elderly and those with physical or mental disabilities. 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.