Part-Time Physician Reviewer (SCAN Temp)

SCAN Group is a not-for-profit organization dedicated to tackling the most pressing issues facing older adults in the United States. SCAN Group is the sole corporate member of SCAN Health Plan, one of the nation's leading not-for-profit Medicare Advantage plans, serving more than 277,000 members in California, Arizona, Nevada, Texas and New Mexico. SCAN has been a mission-driven organization dedicated to keeping seniors healthy and independent for more than 45 years and is known throughout the healthcare industry and nationally as a leading expert in senior healthcare.

SCAN employees are a group of talented, passionate professionals who are committed to supporting older adults on their aging journey, while also innovating healthcare for seniors everywhere. Employees are provided in-depth training and access to state-of-the-art tools necessary to do their jobs, as well as development and growth opportunities. SCAN takes great pride in recognizing our team members as experts in their fields and rewarding them for their efforts. If you are interested in becoming part of an organization that is innovating senior healthcare visit www.thescangroup.org, www.scanhealthplan.com, or follow us on LinkedIn, Facebook, and Twitter.

Job Description:

The Job

With a focus on delivering comprehensive, high quality person-centered care across the health care continuum, the Medical Director will work closely with SCAN healthcare leadership to provide operational expertise and medical decision support for the day-to-day activities in the areas of Utilization Management, Appeals and Grievances, Medical Claims and Medical Policy with the goal to promote strategies and policies that enhance the delivery of the quadruple aim.

This position is remote and supports SCAN Health Plan clinical operations in all geographies of operation and serves as the first point of contact for SCAN's internal clinical teams pertaining to medical management, medical policy, claims, utilization management and quality programs.

This is a part-time position, with an anticipated average of up to 20 hours of work per week.

You Will

Provides medical guidance and interpretation for utilization management operations (prior authorization, concurrent and retrospective review and claims payments).

Provide medical expertise to the medical policy team for questions related to daily operations in accordance to Medicare and SCAN guidelines including recommendations for process modifications to improve efficiency and effectiveness.

Provide clinical review for corporate activities like grievance and appeals.

Engage in peer to peer discussion with Medical Directors of our provider partners regarding grievance and appeals with the goal of reducing pain points in the healthcare continuum for our members.

Streamline corporate activities review escalation process to MD level when appropriate to improve efficiency in accordance with Medicare, State and SCAN guidelines.

Provide medical expertise to the medical management team overseeing out of area members to achieve the best outcomes for quality of care and efficiency.

Review and Represent SCAN in Administrative Law Judge appeal cases.

Participate in IDT rounds with the focus on the quality of care and utilization management.

Support effective implementation of performance improvement initiatives with a focus on 5 star quality improvement for provider partners.

Review quality of care cases and provide recommendations to Credentialing and Peer Review committees.

Review provider and facility claims including complex, controversial, and/or unusual or new services in order to determine medical necessity and appropriate payment.

Contribute to team effort by identifying and achieving goals as needed.

We seek Rebels who are curious about AI and its power to transform how we operate and serve our members.

Actively supports the achievement of SCAN's Vision and Goals.

Other duties as assigned.

While this job description is intended to be an accurate reflection of the essential job results, management reserves the rights to modify, add, or remove duties from particular jobs and to assign other duties as necessary.

Your Qualifications

Required Certifications or Licenses: Physicians (MDs).

Unrestricted California State Medical License required. Licensing in other states will be required to obtain based on business needs. Board Certification in one of ABMS categories required.

Aminimum of five years' experience in active clinical practice in an adult-based primary care specialty (preferably Internal Medicine or Family Practice) is required.

Active or recent hospital experience (within the past five years) is strongly desirable.

Experience in Health Plan /Medical Group operations.

Experience in appeals and grievances review, utilization management, case review, and/or quality improvement activities in a managed care setting is strongly desired.

Strong knowledge of Medicare policies and guidelines is required.

Strong interpersonal skills, excellent written and oral communication skills; commitment to detail.

Demonstrated leadership and management skills.

Strong clinical skills especially in creating evidence based utilization management, disease management and quality improvement programs.

What's in it for you?

• Base salary range: $175 to $200.00 per hour

• Work Mode: Remote

• Medical Benefits

• Paid Sick Time

• Excellent 401(k) Retirement Saving Plan

• Robust employee recognition program

• An opportunity to become part of a team that makes a difference to our members and our community every day!

We're always looking for talented people to join our team! Qualified applicants are encouraged to apply now!

At SCAN we believe that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more.

SCAN is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.

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Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)