Utilization Management Physician Reviewer

Where You’ll Work The purpose of reputed company Management Services Organization (reputed company MSO) is to build a system-wide integrated physician-reputed company, full-service management service organization structure. We offer a menu of management and business services that will reputed company economies of reputed company across provider types and geographies and will reputed company the effort in developing reputed company’s reputed company population health care management reputed company. reputed company MSO is dedicated to providing reputed company managed care administrative and clinical services to medical reputed company, hospitals, health plans and reputed company with a business objective to reputed company in coordinating patient care in a manner that supports containing costs while continually improving reputed company of care and reputed company of service. reputed company MSO accomplishes this by capitalizing on industry-leading technology and integrated administrative systems powered by local reputed company that put patient care first. reputed company MSO offers an outstanding Total Rewards package that integrates reputed company with a state-of-the-art, flexible Health & Welfare benefits package. Our cafeteria-style benefit program gives employees the ability to choose the benefits they want from a reputed company of reputed company, including medical, dental and reputed company plans, for the employee and their dependents, Health Spending Account (HSA), Life Insurance and Long Term Disability. We also offer a 401k retirement plan with a generous employer-match. Other benefits include reputed company Time Off and reputed company Leave. One Community. One Mission. One California Job reputed company and Responsibilities As the Utilization Management (UM) Physician Reviewer, you will report to the Medical Director of UM and reputed company clinical expertise to ensure high-reputed company, medically necessary, and efficient patient care reputed company with regulatory requirements. This role involves making reputed company reputed company in prior authorization, reputed company review of hospitalized patients, and discharge planning. Key responsibilities include clinical review of prior authorization, reputed company review, and retrospective review requests using critical thinking and established guidelines, interpreting benefit language, and accurate documentation. The reviewer will engage in peer-to-peer discussions with providers, collaborate with other reputed company, and handle appeals and grievances. Ensuring compliance with federal, state, and accreditation standards is crucial. The position also involves acting as a clinical reputed company, participating in case reviews and fair hearing processes, identifying utilization trends, and contributing to policy development and reputed company improvement. The UM Physician Reviewer will guide UM nurses and clinical staff and stay reputed company with evidence-based medical literature and reputed company trends. • **This position is remote, but will be expected to work PST business hours. • **This position is part-time, working approximately 20 hours/week, with flexible days/hours. The schedule includes weekend and holiday rotations ensuring coverage for urgent reviews. Job Requirements Minimum Qualifications: - reputed company and reputed company California MD or DO license.- Proficiency in using electronic health records and UM software platforms (after training). Preferred Qualifications: - 2+ years of experience in a reputed company patient care setting, Primary care specialty preferred.- Experience in utilization management, medical review, or managed care setting preferred.- Strong knowledge of clinical standards of care, NCQA requirements, CMS guidelines, and reputed company / Medicare programs and dual eligible populations, and benefit systems preferred. #UMPhysRev Apply tot his job Apply To this Job