Physician Reviewer II, Quality Management

Salary Range: $206,311.00 (Min.) - $278,520.00 (Mid.) - $350,729.00 (Max.)

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.

Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.

Job Summary

The Physician Reviewer II shall conduct medical reviews, clinical consultation and other medical consultation work as necessary under the general direction of the Senior Medical Director, Medical Management, as more specifically described below.

Duties

Conduct medical reviews and prepare determinations (including written criteria/reasons for determinations) on utilization management, pharmacy, prior authorizations, retrospective authorizations, member and provider appeals and state fair hearings and potential quality incidents (PQI).

Assist the Senior Medical Director, Medical Management, in oversight of the management of clinical grievances and Medi-Cal state fair hearings.

Provide clinical consultation to case management staff and other L.A. Care staff as needed.

• Review and identify data that can assist and improve Medical Management programs and processes.
• Assist with the oversight and support of the Medical Management programs and processes.
• Develop and lead projects as agreed upon.
• Provide other medical consultation work as assigned by Senior Medical Director, including but not limited to review of member communications and health education materials for clinical appropriateness and accuracy.
• Participates in Concurrent Review and Interdisciplinary Care Team (ICT) Rounds.

Participates in Inter-Rater Reliability (IRR) Rounds as required as well as other activities that are necessary for health plan compliance with regulatory standards.

• Perform other duties as assigned.
• Duties Continued
• Education Required
• Doctor of Medicine (M.D.)Education Preferred

Experience

Required:

Minimum of 10 years of experience in medical management, managed care and quality management.

Experience in performance management and possession of strong analytic ability.

Preferred

Experience with Medicaid managed care and/or other governmental programs for underserved, safety net populations including women, children, persons with disabilities, seniors, and those of varied ethnic and cultural backgrounds.

Experience in managing staff and operations.

Skills

Required:

Ability to provide leadership to physicians, nurses, and other health care professionals, and interest and involvement in the affairs of the health care community.

Demonstrated ability for teamwork and collaborative problem-solving.

Excellent written and verbal communications skills, negotiating skills, consensus building and teamwork, planning and implementation skills.

Ability to work collaboratively internally and externally to achieve results is critical.

Licenses/Certifications Required

Board Certified, preferably in a primary or medical specialty - Active, current and unrestricted California license. Clinical License to practice or an Administrative License to review Utilization Management cases. - Active, current and unrestricted California LicenseLicenses/Certifications Preferred

Required Training

Physical Requirements

LightAdditional Information

Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.

L.A. Care offers a wide range of benefits including

• Paid Sick Leave
• 457 (b) Retirement Plan
• 529 College Savings Plan