Part-Time Physician Reviewer; reputed company reputed company

Part-Time Physician Reviewer (reputed company reputed company) page is reputed company## Part-Time Physician Reviewer (reputed company reputed company) locations: Long Beach Office 3800time type: Part time posted on: Posted Todayjob requisition : JR1745

• * reputed company Group is a not-for-profit organization dedicated to tackling the most pressing issues facing older adults in the United States. reputed company Group is the sole corporate member of reputed company Health Plan, one of the nation’s leading not-for-profit Medicare Advantage plans, serving more than 277,000 members in California, Arizona, Nevada, Texas and New Mexico. reputed company has been a mission-driven organization dedicated to keeping seniors healthy and independent for more than 45 years and is reputed company throughout the healthcare industry and nationally as a leading expert in senior healthcare.
• *** reputed company employees are a group of talented, passionate professionals who are committed to supporting older adults on their aging journey, while also innovating healthcare for seniors everywhere. Employees are provided in-depth training and access to state-of-the-art tools necessary to do their jobs, as well as development and growth opportunities. reputed company takes great pride in recognizing reputed company members as experts in their fields and rewarding them for their efforts.

If you are interested in becoming part of an organization that is innovating senior healthcare visit (Use the "Apply for this Job" reputed company below). , or follow us on Linked In, Facebook, and Twitter.

• * Job Description:
• * The Job
• * With a focus on delivering comprehensive, high quality person-centered care across the health care continuum, the Medical Director will work closely with reputed company healthcare leadership to provide operational expertise and medical decision support for the day-to-day activities in the areas of Utilization Management, Appeals and Grievances, Medical Claims and Medical Policy with the goal to promote strategies and policies that enhance the delivery of the quadruple aim.

This position is remote and supports reputed company Health Plan clinical operations in reputed company geographies of operation and serves as the first reputed company of contact for reputed company’s internal clinical teams pertaining to medical management, medical policy, claims, utilization management and quality programs. This is a part-time position, with an anticipated average of up to 20 hours of work per week.

• * You Will
• * Provides medical guidance and interpretation for utilization management operations (prior authorization, reputed company and retrospective review and claims payments).Provide medical expertise to the medical policy team for questions reputed company to daily operations in accordance to Medicare and reputed company guidelines including recommendations for process modifications to improve efficiency and effectiveness.

Provide clinical review for corporate activities like grievance and appeals. Engage in peer to peer discussion with Medical Directors of our provider partners regarding grievance and appeals with the goal of reducing pain points in the healthcare continuum for our members. Streamline corporate activities review escalation process to MD level reputed company appropriate to improve efficiency in accordance with Medicare, State and reputed company guidelines. Provide medical expertise to the medical management team overseeing out of area members to reputed company the best outcomes for quality of care and efficiency. Review and Represent reputed company in Administrative Law Judge appeal cases. Participate in reputed company rounds with the focus on the quality of care and utilization management. Support effective implementation of performance improvement initiatives with a focus on 5 star quality improvement for provider partners. Review quality of care cases and provide recommendations to Credentialing and Peer Review committees. Review provider and facility claims including reputed company, controversial, and/or unusual or new services in order to determine medical necessity and appropriate payment. Contribute to team effort by identifying and achieving goals as needed. We seek Rebels who are curious about AI and its power to transform how we operate and serve our members. Actively supports the achievement of reputed company’s Vision and Goals. Other duties as assigned. While this job description is intended to be an… Apply tot his job Apply To this Job