Kaiser Permanente-Washington Permanente Medical Group is seeking a part-time 0.5 FTE Clinical Review Unit Physician to join our WPMG HQ team in Renton, Washington.
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.
Principal Duties and Responsibilities
* 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. * Assists in the development of clinical review criteria and programs. * Provides education, consultation and feedback to other medical directors, review staff and care management related to clinical review criteria and outcomes. * 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. * 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. * 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. * Engage in collegial and respectful telephone conversations with physicians and other health care providers who request consultation regarding coverage issues and discusses options for resolution. * Participates in Administrative Law Judge hearings for beneficiaries as needed. * Supports the timely review of non-urgent pre-service requests for coverage, post-service reviews, provider reconsideration requests and prepayment clinical review of claims within the regulatory time frame. * 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 call via telephone and computer.
Knowledge and Skills Required
* Understanding of broad range of medical knowledge, including primary care and inpatient care. Familiarity with hospital management, case management, utilization review, clinical pathways, and quality management is necessary. Demonstrated communication, strong negotiation and mediation skills. Must employ an understanding of health maintenance organizations, contract language, managed care environments, and modern healthcare management in an integrated group practice setting, including thorough knowledge of industry trends. Suitable typing skills. Preferred * Knowledge of regulatory and certification requirements which impact utilization management, referral management, and care coordination program design.
* Medical Degree MD/DO or better. * Completion of an accredited residency in Internal Medicine or Family Medicine.
* Board Certified by ABMS or member of ACPE * Washington State physician and surgeon license. Preferred * Documentation of additional training in health plan review, utilization management and quality programs. Certificate of Medical Management, MBA, MHA, MPH
Benefits include: Full malpractice indemnification (including tail coverage), medical/dental/vision benefits, 401(k) & employer-paid retirement contributions, paid vacation, CME, long-term disability, long-term care benefits, and the ability to become a shareholder in our group practice. Learn more about WPMG benefits.
Renton, with a population of 101,300, is located on the south shore of Lake Washington with spectacular views of the lake, the Olympics, the Cascades, and Mount Rainier. The Cedar River runs through the heart of downtown and offers an abundance of natural beauty and a run of federally endangered chinook salmon. The City is centrally located for access to the regions' transportation network, accessible by four state and three interstate highways, only minutes away from Seattle, Bellevue, Tacoma and Sea-Tac Airport. Renton's strong economic base, diverse marketplace and favorable business climate have attracted the attention of nationally recognized companies that are looking to provide employees and their families with an outstanding quality of life.
We are dedicated to building lifetime relationships with peers and patients in Washington State's richly diverse communities. Many know the Pacific Northwest as an attractive tourist destination with beautiful scenery, friendly people, and a host of cultural and recreational opportunities. These elements, and others, make Washington an excellent place to live.
Equity, Inclusion and Diversity
In our local communities and across the nation, Kaiser Permanente sets the standard for respectful care. With multicultural staff, equity, inclusion and diversity councils, medical interpretation resources, outreach efforts, educational programs and more, Kaiser Permanente puts people first in our medical centers and beyond.
As part of Kaiser Permanente, Washington Permanente Medical Group (WPMG) seeks to create equity in our communities, eliminate health disparities, and always put patients--the heart of everything we do--first.
Following the guidelines in our National Diversity Agenda, every member of our team strives to:
Provide culturally responsive and appropriate medical care to improve the health and satisfaction of all people in our increasingly diverse membership
Recruit and retain clinicians and staff that enhance our workforce
Grow our membership by providing exceptional service and clinical care to all communities in our region
Creating a diverse workforce, an inclusive environment, and equitable opportunity for employment, growth, and advancement are deeply linked to our mission, our business, and our economic future. WPMG continues to add programs that build and maintain a workplace where we engage with our members, communities, and each other--with dignity, respect, and cultural understanding.
Equal Employment Opportunity
As part of our commitment to our employees and the members and patients we serve, we integrate diversity into all aspects of our operations. Maintaining a workforce with industry-leading levels of diversity through deliberate planning, development, and outreach is critical to fulfilling our mission, sustaining our business objectives, and providing the best level of care to our members and patients. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.