OverviewThe Utilization Management Physician makes coverage determinations about requested services included in Kaiser Permanente members’ benefits packages by exercising clinical judgment, supported by established guidelines and key criteria to determine medical necessity. This position is a full-time administrative physician role.Major Responsibilities:
- Conducts daily utilization management medical necessity reviews and coverage reviews based on individual member’s clinical information, plan benefits, national, state, CMS and proprietary coverage policies, evidence-based references and/or expert opinion and renders determinations including authorizations and adverse determinations.
- Participates in over-the-phone hearings with Administrative Law Judge regarding adverse determinations for members with Oregon Health Plan coverage. Conducts peer to peer calls, when requested, on adverse determinations.
- Provides initial training and ongoing education to, and in collaboration with, utilization management physicians, nurses and support staff.
- Maintains ongoing knowledge of regulatory requirements relevant to utilization management and participates in inter-rater reliability sessions.
- Conducts pre-registration calls to obtain authorizations from non-Kaiser Permanente insurance companies for imaging and procedures to be performed at Kaiser Permanente.
Minimum Education, Licenses and Experience:
- Board certified MD or DO. Current unrestricted medical licensure in Oregon and Washingon.
- Minimum five (5) years of clinical practice.
- Minimum two (2) years of utilization management experience.
Our Northwest Permanente physicians enjoy:
- Generous automatic employer-funded pension and retirement contributions totaling 21% of eligible clinician earnings with additional employee contribution optional.
- Competitive compensation that is not based on fee-for-service model.
- Pathway for physicians to become shareholders of Northwest Permanente.
- Paid annual education leave + annual education allowance.
- Comprehensive benefits including largely employer-funded medical, dental insurance premiums, life insurance, and paid leave.
