DescriptionWe are currently looking for a
Physician Reviewer to join our growing team on a full time basis!
The Physician Reviewer is in a utilization management reviewer role at tango - providing UM case reviews, peer to peer calls/conversations and consultations in real-time; assisting as a resource with functional areas such as utilization management/review, provider relations and communications, and working with physicians to provide education, peer to peer reviews and support.
Office Location:Remote - flexible hours
Essential Functions:- Perform focused real-time case reviews by reviewing the information in the software system(s).
- Applies medical judgement and pertinent evidence based clinical guidelines to determine medical necessity on pre-service, concurrent, and retroactive and claims reviews of medical home health services.
- Reviews Potential Quality Issues (PQIs).
- The Physician Reviewer will provide quality reviews that address the individual needs of the member, align with medical evidence guidelines, and meet compliance requirements.
- The Physician Reviewer will identify and appropriately document areas of inappropriate utilization of resources.
- Participates in inter-rater review cases.
- Perform Peer-to-Peer case discussions with payer medical directors, PCP's, hospitalists and specialists.
- The Physician Reviewer must maintain positive relationships with a variety of external and internal stakeholders, including working closely with primary care physicians, specialists, hospitalist physicians, nursing, therapists, and staff, participate in interdisciplinary team meetings.
- Provides medical guidance and review activities for home health utilization management and medical quality improvement activities and programs in accordance with health plan, regulatory, state, corporate, and NCQA accreditation requirements.
- Attend and participate as assigned quarterly UM, QM and Compliance Committee Meetings.
- Provide input on clinical content for specific programs.
- Evaluate potential quality of care concerns as assigned.
- Assist in developing and reviewing policies as requested/needed.
- Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice and/or return to acute (RTA's) to improve the quality and cost of care.
- Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality for home care services.
- Participate in all aspects of regulatory compliance related to health services functions at tango.
- The physician Reviewer must function within the virtual environment and be able to work individually, while working collaboratively with the clinical/medical management team.
Qualifications:- MD or DO license in good standing and no restrictions in state where UM reviews are conducted.
- Board certified preferable in a primary care specialty (Internal Medicine, gerontology, Family Medicine, Physical Medicine and Rehabilitation).
- Must be an actively practicing physician with 10+ years' practice.
- Course work in the areas of Health Administration, Health Financing and Insurance is helpful.
- Board Certification through American Board Medical Specialties.
Knowledge and Experience:- 3+ years of health plan or IPA experience conducting UM Authorization and determination reviews preferred
- Peer-to-Peer meeting experience
- Medicare Advantage, Medicare and Medicaid experience
- Must be proficient and have good computer and technology skills
- CMS Chapter 7 Home Health knowledge is a plus
- Supports a culture of continuous quality improvement
- 2+ years Milliman Care Guidelines or InterQual experience
