JOB SUMMARY Clinical Reviewer Unit Physicians ensure that requests for coverage are adjudicated using professionally recognized standards and criteria. Requests are reviewed for clinical indications, appropriateness, and compliance with contract language. This is achieved through well documented case review, the consistent application of decision tools, criteria and data collection, and feedback to regional medical directors, program chiefs, individual physicians and care management related to clinical review outcome trends.
PRINCIPAL DUTIES & RESPONSIBILITIES ResponsibilityDescriptionProfessional Competence- Conducts clinical reviews on potential coverage denials based on the application of clinical review criteria and is able to meet the regulatory standards for review timelines.
- Documents the review process and decisions for determination of coverage thoroughly, and submits the outcome, including a summary of rationale that can be used in the letter sent to the patient and providers to the review staff within predefined timelines.
- Works with the external delivery system to ensure their understanding of the referral and clinical review process and its relationship to the clinical review criteria.
- Manage standard and expedited patient appeals within regulatory timelines, seeking specialty expertise when indicated.
- Participates in Administrative Law Judge hearings for beneficiaries as needed.
- Familiarity with hospital management, case management, utilization review, clinical pathways, and quality management.
- Must employ an understanding of health maintenance organizations, contract language, managed care environments and modern healthcare management in an integrated group practice setting, including through knowledge of industry trends.
Teamwork and Collaboration- Assists in the development of clinical review criteria and programs.
- Able to work well with other health professionals (RN's, case managers) to effectively facilitate appropriate level of care for KPWA patients in a variety of care settings.
- Comanage concurrent review with the Centralized Inpatient Administration team in an effort to help achieve organizational targets.
- Works with the Clinical Guidelines staff, Medical Technology Committee, and Pharmacy and Therapeutics Committee in reviewing requests for new services to determine whether they are medically necessary, effective or experimental or investigation.
- Assist in weekend calls via telephone and computer.
Service Excellence- Provides education, consultation and feedback to other medical directors, review staff and care management related to clinical review criteria and outcomes
- Provides physician review component to determine appropriate coverage, level of care, length of stay for hospital, skilled nursing facility, inpatient rehabilitation and long-term acute care facilities. Work with KPWA care managers managing review of hospital admissions, transfers, discharges. Understanding of appropriate levels of care including inpatient, LTAC, skilled nursing care, and custodial care.
JOB SPECIFICATIONSEDUCATIONREQUIREDDESCRIPTIONPREFERREDMinimum:
Medical Degree: MD, DO
Completion of an accredited residency in internal or family medicine
Documentation of additional training in health plan review, utilization management, and quality programs. Certificate of Medical Management, MBA, MHA, MPH
EXPERIENCEREQUIREDDESCRIPTIONPREFERREDMinimum:
3 or more years of clinical practice experience, including outpatient primary care, and one year of experience in utilization/quality management, including a minimum one year of experience as a hospitalist or extensive hospital rounding experience
Four to six years' experience in clinical practice with two to four years of experience as a hospitalist or extensive hospital rounding experience
One to two years of experience as a nursing home attending with an additional three years in utilization/quality management, and some related to health plan management
Experience leading teams in analysis, planning, implementation and monitoring the implementation of new programs and processes, clinical pathways and quality management
Knowledge of regulatory and certification requirements, which impact utilization management, referral management and care coordination design
LICENSES, CERTIFICATIONS OR OTHER ESSENTIAL QUALIFICATIONSREQUIREDDESCRIPTIONPREFERREDMinimum:
Washington State physician and surgeon license
A current license to practice without restriction
Credentialed by KPWA
Washington Permanente Medical Group Health Shareholder
Board Certified by ABMS or member of ACPE
None
COMPETENCIESCompetencies: Skills, Knowledge & Behaviors that are required for performing the job.
COMPETENCIESDESCRIPTIONREQUIRED/PREFERREDChampions Innovation and Change
Ability to identify opportunities and generate ideas for change and innovation.
Demonstrated ability to implement change initiatives and create sustainable improvement.
Superior critical thinking and analysis skills required.
Foster a continuous improvement culture.
Required
Collaborates
Builds productive rapport with key stakeholders.
Exceptional customer service and networking skills. Ability to work with high level leaders.
Creates opportunities for teams to improve effectiveness and share information.
Fosters an inclusive work environment.
Required
Communicates Effectively
Demonstrated communication, strong negotiation, and mediation skills.
Clearly and concisely communicates verbally and in writing.
Encourages, respectfully listens to and acknowledges diverse points of view.
Develops shared knowledge to understand what type of and how much information to share for joint success.
Clearly communicates roles, goals, and expectations to direct reports.
Required
Focuses on the Customer
Recognizes and resolves problems impacting customers in a timely and professional manner.
Sets and adjusts priorities to meet customers' needs.
Anticipates customer problems, proactively addresses issues.
Models the KP experience standards with staff and customers.
Required
Develops Self and Others
Takes responsibility to build skills and capabilities to enhance performance.
Learns from mistakes.
Gives direct, constructive feedback to improve performance and grow capability.
Effectively delegates, sharing responsibility with others, with sufficient structure, support and monitoring of progress.
Required
Drives for Results
Thinks of ways to improve results and achieves excellence.
Makes timely, effective day-to-day operational decisions.
Clearly articulates desired results and connection to intended impact and purpose.
Delegates decisions to lowest level possible and empowers others to perform.
Required
Takes Accountability
Consistently meets commitments to customers, colleagues, and manager.
Takes personal responsibility for own behaviors, results, and decisions.
Engages fully in work, takes immediate and independent action when needed.
Exhibits self-awareness and cultural agility.
Required
DISCLAIMER: The above statements are intended to describe the general nature and level of work assigned to this job. This is not intended to be an exhaustive list of all of the responsibilities, duties, and skills required. The time devoted to the activities listed may be changed and other duties may be assigned. 
