Physician Reviewer, Select Health

Job Description:

Select Health is a not-for-profit community health plan serving more than 1 million members in the Intermountain West. Select Health’s line of businesses (LOB) includes Medicare, Medicaid, FEHB, Marketplace Qualified Health Plans and fully funded and self-funded Commercial plans. This position is responsible for providing physician peer review and clinical direction for Select Health including utilization management, case management, appeals, criteria and policy development and other projects as needed.

This position is responsible for working with all the departments of Select Health, but primarily Utilization Management, Benefits Determination, Quality Improvement, Behavioral Health, Pharmacy Services, other Select Health Departments, and other Intermountain Health division as needed to implement policies and programs for the Office of the Medical Director to manage the provider panel and to maintain high customer satisfaction.

Act as the first level of reviews and appeals for panel providers or members' concerns regarding coverage/benefits issues or quality of care.

• Assist in the development and review of Utilization Management screening criteria & policies used in the preauthorization process.
• Participate in the yearly guideline review process.
• Participate in ongoing evaluation of the UM process.
• Participate in a physician specialty panel to assist in peer review of cases and specified turnaround times by accreditation or licensing bodies.

Provide clinical education to members of the UM/CM and HCS staff as necessary to perform their function.

Review preauthorization requests which fail to pass criteria as applied by staff and document those utilization and case management decisions appropriately in the care management system.

Represent Select Health on committees as assigned by the Medical Director.

Serve as a resource for the Select Health Medical Director in recommending ways to improve health services delivery and reduce medical expenses without compromising quality of care. Constantly stress and strive for cost-effectiveness on the part of physicians and ancillary health care providers.

Assist and support Health Care Services departments as needed in maintaining NCQA, HEDIS, and CAHPS certification, and other contractual requirements such as Medicare, Medicaid, CHIP, exchange plans and FEHB compliance.

In cooperation with Medical Director, writes and updates medical policies. Interacts with the delivery system including clinical programs, individual physicians and clinics to align care process models and clinical practice to evidence based standards.

• Leadership
• Performance Metrics
• Results-Oriented
• Communication
• Problem Solving
• Taking Initiative
• Analytical Thinking
• Accountability
• Collaboration
• Professional Etiquette

Medical Doctor or Doctor of Osteopathic Medicine degree with Board Certification in specialty. Degree must be obtained through an accredited institution. Education is verified. Requires current MD or DO licensure within the State of Utah, Idaho, Nevada or Colorado Five years of experience in clinical practice. Experience in a role requiring effective verbal, written, and interpersonal communication skills.

Training in clinical quality improvement. Prior experience with Intermountain Health. Experience working in an integrated healthcare system. Knowledge of managed care products and processes as well as the impact of managed care on the market and cost of health care. Knowledge of the NCQA accreditation standards and process.…