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Utilization Management Physician Advisor, CA Licensed (Part Time)

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.***MUST HAVE UTILIZATION MANAGEMENT EXPERIENCE*** Utilization Management Physician Advisor works with Senior Medical Officers, Regional Medical Officers, Extensivists, the Healthcare Services Team (Case managers, Social Workers, Utilization Managers) to develop and implement methods to optimize use of Institutional and Outpatient services for all patients while also ensuring the quality of care provided. Through remote access to our web-based Portal, physician advisors will complete clinical reviews for medical necessity, treatment appropriateness and compliance.GENERAL DUTIES/RESPONSIBILITIES:Perform medical necessity utilization reviews primarily for inpatient and post-acute cases with some outpatient / pre-service reviews as needed in accordance with UM guidelines Lead concurrent review activities, including rounds, peer-to-peers, and utilization management strategies to improve clinical and efficiency outcomes Serve as a clinical leader and educator for the nursing / care management team Process claims reviews, appeals, and second-level reviews as needed in compliance with Medicare (NCD, LCD), internal, and third-party guidelines (e.g., MCG) for Inpatient, Outpatient, Skilled Facilities Level of Care and Pharmacy. Acts as a liaison between the medical staff, utilization review team, and 3rd parties to effectively promote clinically necessary and efficient utilization of care Serves as a Physician member of the utilization review team. Work with Interdisciplinary Teams to help manage complex or high risk cases Contributes to development of clinical strategies to improve member outcomes, efficiency metrics, and quality outcomes Duties may include serving on committees as needed, such as quality, utilization management, credentialing, etc Other duties as may be assigned to the medical director.Supervisory Responsibilities:Oversees assigned staff, if any. Responsibilities may include recruiting, selecting, orienting, and training employees; assigning workload; planning, monitoring, and appraising job results; and coaching, counseling, and disciplining employees.Experience:• Required: Minimum of 3 years of experience in hospital-wide or skilled nursing facility position involving clinical care, quality management, utilization / case management, or medical staff governance required• Preferred: Experience as a Physician Advisor or Medical Director a plusEducation:<ul><li>Required: Completion of medical school and specialty residency (preferably in internal medicine).</li><li>Preferred: Board-certification</li></ul>Specialized Skills:• Required:<ul><li>Utilization Management Experience</li><li>Ability to build rapport with medical staff and management leadership to obtain necessary approvals of new strategies for utilization management.</li><li>Knowledge of current medical literature, research methodology, healthcare delivery systems, healthcare financial/reimbursement issues, and medical staff organizations.</li><li>Dedication to the delivery of high-quality, cost-effective, efficient patient care services</li><li>Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors;</li><li>Mathematical Skills: Ability to perform mathematical calculations and calculate simple statistics correctly</li><li>Reasoning Skills: Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution.</li><li>Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.</li></ul>Licensure:• Required: California License, Applicants must have current, non-restricted licensure as required for clinical practice in the state of California.Work Environment:This is a remote position. The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.Essential Physical Functions:The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.1 While performing the duties of this job, the employee is regularly required to talk or hear.2 The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.3 The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.Pay Range:Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc. Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at <a href="https://protect-us.mimecast.com/s/P1GaC82l6KF8ygOUngCFQ/" target="_blank" rel="noopener noreferrer">https://reportfraud.ftc.gov/#/</a>. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email <a href="mailto:careers@ahcusa.com" target="_blank" rel="noopener noreferrer">careers@ahcusa.com</a>.

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