Physician Reviewer, Select Health

Job description

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. Essential Functions Coverage & Benefits determinations: Act as the first level of reviews and appeals for panel providers or members' concerns regarding coverage/benefits issues or quality of care. Utilization Management: 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. Education: Provide clinical education to members of the UM/CM and HCS staff as necessary to perform their function. Preauthorization and appeals: 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. Committees: Represent Select Health on committees as assigned by the Medical Director. Delivery Improvement: 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. Certification Requirements: 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. Medical Policy: 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. Skills Leadership Performance Metrics Results-Oriented Communication Problem Solving Taking Initiative Analytical Thinking Accountability Collaboration Professional Etiquette Minimum Qualifications 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. Preferred Qualifications 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. Understanding of health care delivery system as it relates to government programs and agencies Physical Requirements Interact with others requiring employee to verbally communicate as well as hear and understand spoken information. Operate computers, telephones, office equipment, and manipulate paper requiring the ability to move fingers and hands. See and read computer monitors and documents. Location: SelectHealth - Murray Work City: Murray Work State: Utah Scheduled Weekly Hours: 20 The hourly range for this position is listed below. Actual hourly rate dependent upon experience. $7.25 - $999.99 We care about your well-being – mind, body, and spirit – which is why we provide our caregivers a generous benefits package that covers a wide range of programs to foster a sustainable culture of wellness that encompasses living healthy, happy, secure, connected, and engaged. Learn more about our comprehensive benefits package here . By applying for a position with Intermountain, I acknowledge that I will comply with all applicable Intermountain policies and expectations. If applying for a remote or hybrid role, this includes remote work expectations related to confidentiality, information security, work schedules, conflicts of interest, and use of company equipment. I further acknowledge that outside employment or activities may not interfere with job responsibilities or create a conflict of interest with Intermountain. Actual or reasonably perceived conflicts may be grounds for disqualification from consideration or, if hired, corrective action up to and including termination of employment. Intermountain Health is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability or protected veteran status. 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