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The stated pay scale reflects the range that Sharp reasonably expects to pay for this position. The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant's years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.

What You Will Do

The position is responsible for the performing medical utilization reviews and appeals and grievance reviews under the direction of the Senior Medical Director or designee for Sharp Health Plan (SHP).

The Physician Reviewer will perform all reasonably necessary functions to ensure quality of care and appropriate utilization in the most cost-effective, appropriate and professional manner, which meets the expressed needs of patients and professional colleagues.

Required Qualifications

• Doctor of Medicine (MD) OR
• Doctor of Osteopathic Medicine (DO)
• 5 years' experience as a practicing primary care physician with knowledge of managed care and the process for prior authorization review.
• California Physicians and Surgeons License - Medical Board of CA -REQUIRED

Other Qualification Requirements

• Board Certification in Internal Medicine or Family Medicine preferred.

Essential Functions

• Physician Responsibilities

• Performs Medical Necessity Reviews including utilization management and appeals and grievances. Assists physician team in researching and writing clinical policies consistent with evidence-based guidelines .

• Customer service
  Provides prompt, accurate, and excellent services to internal divisions. .
  Develops solid professional working relationships with various internal departments and units and, as required, vendors and providers.

• General support
  Participates in special projects and other duties as assigned. These may include, but are not limited to, work groups, audits and back-up medical management support for the Medical Directors.

• Professional competency
  Maintain current knowledge of the service denial process and pertinent health plan authorization criteria and regulations.
  Keeps abreast of advances in medical care methodologies that may contribute to enhanced quality of services and effective utilization of services.

• Provider interaction
  Periodically presents information regarding authorization services at various SHP meetings on an as needed basis.
  Provides educational support for PCPs through collaboration with PMG Medical Directors in regard to proper utilization authorization.
  Provides strong leadership and direction for appropriate and efficient prior authorization services.

• Training
  Participate in yearly Milliman inter-reliability rate (IRR) and Hayes Technology Assessments training.

Knowledge, Skills, and Abilities

• Knowledge of physician social and political behavior and managed care philosophy.
• Demonstrate effective communication skills, ability to work collaboratively with medical leadership and administration of SHP, medical staff, nurses, and Sharp entities.

Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class.

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