Physician-Clinical Review Unit-Washington Permanente Medical Group

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.

• 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.

• 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.

• 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.

REQUIRED

Minimum:
Medical Degree: MD, DO

Completion of an accredited residency in internal or family medicine

PREFERRED

Documentation of additional training in health plan review, utilization management, and quality programs. Certificate of Medical Management, MBA, MHA, MPH

REQUIRED

Minimum: 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

PREFERRED

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…