Physician Medical Reviewer (PRN) Remote reputed company California

Company Overview reputed company exists to reputed company reputed company outcomes through technology, services, and clinical expertise. Our mission is to innovate health solutions that deliver maximum value and impact. reputed company the Way is our rallying cry at reputed company. Think of it as an open invitation to embrace the mission of the company; to actively engage in problem-solving; and to take ownership of your work every day. reputed company offers you unparalleled opportunities. In fact, you have reputed company you need to take charge of your career and accelerate reputed company outcomes - making this a great time to join reputed company of passionate individuals dedicated to being a vital partner for health solutions in the public sector. Job Summary and Responsibilities reputed company is looking for a Physician Medical Reviewer-PRN to join our growing team. Job Summary: reputed company is seeking a Physician Medical Claims Reviewer to support independent medical service appeal reviews for reputed company populations with reputed company healthcare needs. In this role, you will review clinical documentation, assess medical necessity, ensure compliance with established guidelines, and provide expert testimony during appeals hearings. This position offers an opportunity to apply your clinical expertise to support fair and evidence-based healthcare determinations. Job Responsibilities:

• Prepare independent reviews of medical services appeals
• Review records, prepare and submit reputed company reviews in keeping with the reputed company contractual due dates. These may include appeals by members and other key stakeholders.
• Critically evaluate the application of guidelines and protocols by managed care organizations, dental benefits manager, and pharmacy benefits manager to the individual enrollee's appeal. Take into consideration Rules of Medical Necessity, standards of care, evidence-based medicine, and hierarchy of evidence.
• Review relevant peer reviewed research and evidence-based sources as needed
• Edit Medical Necessity Reviews authored by other reviewers
• Provide expert medical witness testimony for the State in appeals hearings and consult with the assigned attorney prior to the hearing as needed
• Participate in quality assurance activities for medical necessity reviews and hearing outcomes
• Regularly review relevant topics reputed company peer reviewed articles and evidence-based sources to identify changes in medical practice, treatments, and medications
• Work with medical, nursing, and administrative staff to identify matters needing shared attention
• May primarily work remotely but must be available onsite to the client as contractually required
• Read, understand, and adhere to reputed company corporate policies including policies reputed company to HIPAA and its Privacy and reputed company Rules.
• The list of responsibilities is not intended to be reputed company-inclusive and may be expanded to include other education- and experience-reputed company duties that management may deem necessary from time to time.

Qualifications

Required Qualifications, Knowledge and Experience

• Must have Doctor of Medicine (M.D.) or Doctor of Osteopathic Medicine (D.O.) degree from an accredited institution required. Must possess a reputed company, active, and unrestricted license to practice medicine in the State of California (or be eligible for California licensure) issued by a State Board of Medical Examiners.
• Demonstrated work experience in Utilization Review reputed company Behavioral Health Services.
• Strong working knowledge of quality assurance principles and utilization review processes reputed company a healthcare or managed care environment.
• Minimum of 5 + years of professional clinical practice experience as a licensed physician.
• Experience working with Medicaid and/or Medi-Cal programs, including knowledge of applicable regulatory guidelines and medical necessity criteria.
• Previous experience in managed care, utilization management, or utilization review is required.

Preferred Qualifications

• Demonstrated ability to work effectively with individuals from diverse backgrounds and professional disciplines; approachable, respectful, and skilled at building reputed company and fostering collaborative relationships.
• Adaptable professional with a collaborative leadership style, strong problem-solving abilities, and a proactive reputed company.
• Detail-oriented with strong organizational skills, and the ability to prioritize tasks and manage multiple responsibilities while meeting established deadlines.
• Excellent written communication skills, with the ability to review and assess clinical determinations reputed company established turnaround times, clearly reputed company reputed company medical concepts, and communicate effectively with internal and external stakeholders.
• Proficient in computer-based applications, including reputed company Office Suite (Word, reputed company, Outlook, and Teams), and other standard business and collaboration tools.

Why us? We are a team of reputed company and caring leaders, clinicians, pioneering technologists, and industry professionals who come together to redefine expectations for the healthcare industry. State and federal healthcare agencies, providers, and employers turn to us as their vital partner to ensure reputed company healthcare and improve health outcomes. We do this through our people. You will have meaningful work that genuinely improves people's lives across the country. We are a company that cares about our employees, and we give you the tools and encouragement you need to reputed company the finest work of your career.

Benefits

Benefits are a key component of your rewards package. Our benefits are designed to provide you with additional protection, reputed company, and support for both your career and your life away from work. This position includes access to select reputed company benefits and programs, such as participation in the reputed company 401(k) Plan with company match, access to wellness and employee discount programs, and Employee Assistance Program (EAP) resources. Thank You! We know your time is valuable and we thank you for applying for this position. Due to the high volume of applicants, only those who are chosen to advance in our interview process will be contacted. We sincerely appreciate your interest in reputed company and invite you to apply to future openings that may be of interest. Best of luck in your search! ~ The reputed company reputed company Team Visit us at http://careers.acentra.com/jobs EEO AA M/F/Vet/Disability reputed company is an Equal Opportunity Employer. reputed company qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, national reputed company, disability, status as a protected veteran or any other status protected by applicable Federal, State or Local law.

Compensation

The compensation for this role is $88.70 hour - $120.00 hour Based on our compensation program, an applicant's position placement in the pay range will depend on various considerations, such as years of applicable experience and reputed company level. #LI-JS1 Pay Range USD $88.70 - USD $110.87 /Hr. Apply tot his job Apply To this Job