This is a fully remote position, open to applicants in California.

📋 Description

• Collaborates with Senior Medical Officers, Regional Medical Officers, Extensivists, and the Healthcare Services Team to enhance the utilization of Institutional and Outpatient services.

• Performs clinical evaluations to assess medical necessity, treatment appropriateness, and adherence to compliance standards.

• Assigns appropriate levels of care classifications and conducts continued stay reviews in accordance with CMS and Milliman guidelines.

• Functions as a liaison among medical staff, utilization review, and third-party payers to ensure proper levels of medical care.

• Oversees the complete claim denial process, which includes Appeals and Grievances.

• Acts as a Physician member of the utilization review team.

⛳️ Requirements

• A minimum of 3 years of experience in a hospital-wide or skilled nursing facility role that involves clinical care, quality management, utilization and case management, or medical staff governance is required.

• Completion of medical school and a specialty residency is required (preferably in internal medicine).

• Current, unrestricted licensure required for clinical practice in the state of California.