Physician Reviewer

Overview

What you can expect! 

 

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience!

 

The Physician Reviewer provides support in clinical decision-making oversight and physician level guidance in quality management, utilization management, and care management. The Physician reviewer supports all IEHP departments in meeting the regulatory requirements set forth by the various government agencies.

The Physician Reviewer shall perform Medical Review activities and provide IEHP Medical Director support. The Physician Reviewer shall perform determinations, communicate medical necessities and support IEHP Medical Director(s) as needed or requested by IEHP.

 

Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Additional Benefits

Perks

 

IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more.

• Competitive salary.
• Hybrid schedule.
• CalPERS retirement.
• State of the art fitness center on-site.
• Medical Insurance with Dental and Vision.
• Life, short-term, and long-term disability options
• Career advancement opportunities and professional development.
• Wellness programs that promote a healthy work-life balance.
• Flexible Spending Account – Health Care/Childcare
• CalPERS retirement
• 457(b) option with a contribution match
• Paid life insurance for employees
• Pet care insurance

Key Responsibilities

Provide medical expertise, clinical judgement and accepted medical standards in clinical decisions to ensure services provided are medically necessary and appropriate and meet professionally recognized standards.

Conduct review of routine/urgent medical service requests based on medical necessity including but not limited to prior authorizations, inpatient care, DRG reviews, quality reviews and grievances.a. Determinations shall be completed prior to the due date delineated in IEHP’s care management system. Some due dates will also       include weekend(s) and holidays.b. Turnaround times shall be in accordance with Medicare and Medi-Cal regulations.c. Perform all services in IEHP’s clinical care management systems.

Review and provide Medical Director support as needed and requested by IEHP, i.e., policy review, committee participation or ICT support.a. Reviewer shall be supported by IEHP’s nurse and non-clinical staff in the set up and completion of medical case reviews.

Conduct peer-to-peer discussions regarding determinations when applicable.

Participate in ad hoc training sessions to become familiar with IEHP clinical care management systems.

Provide direction of current clinical practices for health services.

Participate in health quality improvement efforts while helping to manage health plan resources assuring an appropriate and efficient health care delivery system for IEHP members and supporting IEHP strategic goals.

Assist Medical Directors in providing medical direction and guidance to the Health Services Department in the area of inpatient, outpatient pre-service authorizations, grievances, quality reviews and the coordination of care with external agencies, consultation on complex cases, and participation in Interdisciplinary Care Teams/case conferences.

Provide  clinical support to IEHP committees.

Perform any other duties as required to ensure Health Plan operations and department business needs are successful, under the guidance of the Medical Director.

Qualifications

Education & Requirements 

• Five (5) years or more of post-residency experience in a recognized medical specialty is required.

• Medical Director for an IPA, medical group, or HMO highly desirable. Utilization management experience is a plus. Primary Care Physician in internal medicine, family practice, or pediatrics preferred.
• At least one (1) year of medical leadership experience preferred.
• Doctor of Medicine or Psy.D from an accredited institution required.
• Certification by one (1) of the American Specialty Boards required.
• Possession of an active, unrestricted, and unencumbered Physician’s and Surgeon’s Certificate issued by the State of California Medical Board or a Clinical Psychologist License issued by the California Board of Psychology required.
  • A physician certified in a state othe