Physician Reviewer

If you are as passionate about helping those in need as you are about growing your career, consider AltaMed. At AltaMed, your passion for helping others isn’t just welcomed – it’s nurtured, celebrated, and promoted, allowing you to grow while making a meaningful difference. We don’t just serve our communities; we are an integral part of them. By raising the expectations of what a community clinic can deliver, we demonstrate our belief that quality care is for everyone. Our commitment to providing exceptional care, despite any challenges, goes beyond just a job; it’s a calling that drives us forward every day.

The Physician Reviewer, Medical Management, provides a routine review of authorization requests from all lines of business using respective national/state health plans and nationally recognized guidelines where appropriate, to guide the processing of referrals. The Physician Reviewer approves authorizations per delegation responsibilities in the AltaMed Authorization Matrix and, where applicable, per their training and licensing restrictions. The Physician Reviewer, Medical Management processes denials of authorizations using standard denial language noted from the above hierarchy of guidelines and posts recommendations in the authorization platform to inform the Medical Director workflow. Physician Reviewers of Medical Management review and make recommendations on retro claims reviews for outpatient authorization, inpatient authorizations, and Emergency Room claims. Physician Reviewer, Medical Management may be involved in ad hoc projects and analysis of high-cost utilization areas, unmanaged care, inappropriate utilization, billing practices, and budgeting/finances reporting. The Physician Reviewer, Medical Management is responsible for identifying high-risk populations via provider/clinic referral, utilization management referral, disease registry reporting mechanisms, and patient self-referral, and will refer high-risk patients to appropriate case management programs. With the approval of the Medical Director of Pediatric Utilization Management, Physician Reviewer, Medical Management provides oversight, guidance, and training sessions to UM nurse reviewers and other UM staff, where applicable. This position will provide case management to patients admitted to the hospital and those who may need to be enrolled in ambulatory case management. The Physician Reviewer, Medical Management works as part of an interdisciplinary care team participating in the coordination of care with social work and mental health counseling, psycho-social support services, in-home support, legal services, skilled nursing, home health, etc.  

AltaMed Health Services Corp. will consider qualified applicants with criminal history pursuant to the California Fair Chance Act and City of Los Angeles Fair Chance Ordinance for Employers. You do not need to disclose your criminal history or participate in a background check until a conditional job offer is made to you. After making a conditional offer and running a background check, if AltaMed Health Service Corp. is concerned about a conviction directly related to the job, you will be given a chance to explain the circumstances surrounding the conviction, provide mitigating evidence, or challenge the accuracy of the background report.