About Us
Washington Permanente Medical Group (WPMG) is a clinician-led, self-governed and independent multi-specialty group practice, providing care to the more than 700,000 Kaiser Permanente patients in Washington state. We work unencumbered by traditional health care obstacles and without silos; prioritizing people over profits, collaboration over ego, and driven by a singular goal: our patients' health. At WPMG, we take care of the whole person, with a team to address the fundamental, social, and emotional needs that contribute to total health. We are clinicians motivated by the desire to make a purposeful difference in the communities we serve, and in how health care is delivered.
Summary
Kaiser Permanente-Washington Permanente Medical Group is seeking an Hourly Locums Clinical Review Unit Physician to join our team. This position will begin on July 1, 2022.
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.
Certificate of Medical Management, MBA, MHA, MPH
As a condition of employment, all clinicians and employees are required to verify COVID-19 vaccination status. As part of the pre-boarding process and before starting work, you will be required to verify your vaccination status, and will be provided an opportunity to apply for an accommodation based on a religious or medical reason, if needed.
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.
