The Physician Reviewer of Utilization Management will provide routine review of authorization requests from all lines of business using respective national/state, health plan, nationally recognized guidelines where appropriate to provide guidance for processing of referrals to Medical Director staff and to UM staff. Physician Reviewers may approve authorizations per delegation responsibilities in AltaMed Authorization Matrix and where applicable per restrictions of their training and licensing. Physician Reviewers will process Denials of authorizations using standard denial language noted from above hierarchy of guidelines and post recommendations in the authorization platform to inform Medical Director workflow. Physician Reviewers may review and make recommendations on retro claims reviews for outpatient authorization, inpatient authorizations, and Emergency Room claims. Physician Reviewer may be involved in ad hoc projects and analysis of high cost utilization areas, unmanaged care, inappropriate utilization, inappropriate billing practices, and budgeting/finances reporting. May be responsible for identifying high risk population 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 program per AltaMed Case Management Policy. With the approval of the Medical Director of Medical Management, Physician Reviewers may provide oversight, guidance, and training sessions to UM nurse reviewers and other UM staff where applicable. This position will provide case management to patients who are admitted to the hospital and those patients who may need to be enrolled in ambulatory case management. The Physician Reviewer may work 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. Effectively collaborates with the hospitalist, the hospital nursing personnel, with members of the interdisciplinary care team and with the physicians in the clinic.
Responsibilities
- Responsible for the daily review and processing of referral authorizations in accordance to turnaround time (TAT) standards set by ICE/Health Plan
- Works collaboratively with Hospitalists, hospital partners, and care teams to provide holistic patient care that is focused on high quality in a cost effective
- Monitors ongoing services and their cost effectiveness; recommending changes to the plan as needed using clinical evidence-based criteria – Milliman, Interqual, CMS, National Recognized American Academy of Specific Specialty, Health Plan specific criteria.
- Assists with composing medical director denials to meet language requirements set by ICE/Health Plan requirements
- Utilizes authorization matrix, ancillary rosters, DOFR, and/or delegation agreements to drive decision-making
- Maintains up to date knowledge of rules and regulations governing utilization management processes;
- Input data into the Medical Management system to ensure timeliness of referral processing.
- Verifies member benefits and eligibility upon receipt of the treatment authorization request.
- Ensure timely provider and member oral and written notification of referral decisions.
- Coordinates with Medical Director, UM nurses or referral specialists for timely referral processing
- Facilitates LOA processing by sending request to Provider Contracting for non-contracted providers or facilities, when applicable
- Facilitates LOA processing with the Health Plan for non-contracted facilities
- Performs trouble-shooting when problems situations arise; taking independent action to resolve the less complex issues.
- Assist supervisor/manager in quality assurance processes and education of staff
- May be responsible for daily concurrent review, retro reviews, ER reviews, discharge planning, pre-certification/prior authorization request review and ensures patients meet appropriate level of care based on acceptable evidenced based criteria.
- Participate in ad hoc projects and analysis of high cost utilization areas, unmanaged care, inappropriate utilization, inappropriate billing practices, and budgeting/finances reporting
- With the approval of the Medical Director of Medical Management, Physician Reviewers may provide authorization review oversight, guidance, and training sessions to UM nurse reviewers and other UM staff where applicable
- Will participate in the developing of all program material, Policies and Procedures related to the medical management; to include, the development of informational and educational materials
- Develops a positive working relationship with internal and external customers
- Perform additional duties as assigned.
I. MEETS PERFORMANCE REQUIREMENTS
- Meet the established Performance & Productivity Targets. Measurement: Department’s Performance Metrics.
- Effective time management demonstrated by meeting all regulatory and health plan requirements. Measurements, 100% of audits completed and documents submitted within the required time line. No more than three CAPS per health plan per audit.
- Managing multiple priorities, demonstrated by ease and productivity to transition between multiple tasks. Measurement, Department Performance Measure.
- Team player, measured through assisting co-workers with their workload as asked by the Manager/Supervisor/Lead or others and completed cross- training, and serve in roles not their own during the year.
- Meet Productivity Targets, as managed and communicated through the Productivity Report.
- Highly effective communication with members, external constituents, and internal stakeholders. Measurement, Member Satisfaction with Case Management and internal customer feedback.
- Leading by example. Be the role model in offering supportive care to patients, and consistently meet needs of the external and internal customers. This is measured by AIDET Validation and input from the clinics and other customers obtained as a part of the annual Performance Review.
II.EXCEEDS PERFORMANCE REQUIREMENTS
- All items listed under “Meets Expectations”, and;
- Problem solving skills demonstrated by identification, recommendation, and implementation of tactics and approaches to improve productivity and team work.
- Taking initiations demonstrated by consistent and active offer participation to be a positive change agent, to problem solve, identify and offer. suggestions to improve outcomes in Case Management, and to assist others as needed
Qualifications
- MD/DO, Physician Training Program completed, Board Certified Preferred
- Graduation from an accredited medical training program.
- CA Physician License in good standing
- 3+ years of Health Plan or IPA experience doing UM Authorization Reviews
- 3+ years of experience decisioning cases using Medi-Cal and Medicare guidelines
- 3+ years of experience using InterQual or MCG
- Board Certified in Internal Medicine, Family Practice, or Pediatrics
Skills and Abilities
- Experience and training as a Primary Care Physician; experience and expertise in the prevention, diagnosis, and treatment of the illnesses and social problems of the AltaMed population; experience and leadership skills in managing medical resources, monitoring the cost effectiveness and quality of services to participants.
- Demonstrated ability to work with automated systems, including electronic medical records and MS Office products such as Word, Excel and Outlook.
- Exceptional oral and written skills.
- Excellent customer service; ability to be an effective communicator
- Excellent critical thinking, deductive reasoning and decision making skills.
- Ability to work as a team member and participate in the assessment and evaluation process of potential and existing participants.
- Fosters a cooperative and harmonious working climate conducive to maximize employee morale and productivity.
- Knowledge of federal, state and other applicable standards for clinical practice for assigned area(s) of responsibility.
- Ability to work collaboratively with diverse individuals and situations, including strong problem solving and conflict resolution skills.