Work From Home - $250K Per Year
* CA Physician License in good standing
* 3+ years of Health Plan or IPA experience doing UM Authorization Reviews
* 3+ years of experience decisioning cases using Medi-Cal and Medicare guidelines
* 3+ years of experience using InterQual or MCG
- Approve or Deny authorizations
- Review claims for outpatient authorization, inpatient authorizations, and Emergency Room claims.
- Physician Reviewers may provide oversight, guidance, and training sessions
- Responsible for the daily review and processing of referral authorizations in accordance to turnaround time (TAT) standards set by ICE/Health Plan
- Monitors ongoing services and their cost effectiveness; recommending changes to the plan as needed using clinical evidence-based criteria - Milliman, Interqual, CMS, National Recognized American Academy of Specific Specialty, Health Plan specific criteria.