Physician Advisor

By leveraging our world-class technology platform, innovative care delivery models, deep physician partnerships and our serving heart culture, Alignment Health is revolutionizing health care for seniors! From member experience professionals and clinicians, to data scientists and operations leaders, we have built a talented and passionate team that is deeply committed to our mission of transforming health care for the seniors we serve.

The Physician Advisor works with Senior Health Plan Medical Director and Utilization Management team to ensure medically necessary use of hospital services, manage total cost of care and ensure that benefits are administered appropriately. Through remote access to our web-based Portal, Physician Advisor will complete clinical reviews for medical necessity for hospital admissions, evaluate appropriate level of care and manage catastrophic inpatient cases.

Responsibilities

• Perform utilization reviews for hospital admissions in compliance with Medicare 2 midnight rule, NCD & LCD, Milliman guidelines, evidence based guidelines and health plan guidelines.
• Participate in inpatient concurrent review rounds with multi-disciplinary team.
• Perform medical necessity review for inpatient versus observation level of care, in compliance with Medicare 2-Midnight rule.
• Collaborate with case managers from both health plan and relevant medical groups to provide guidance of inpatient medical necessity.
• Perform peer to peer with hospital physicians or hospital utilization review team to establish the right level of care, or to discuss appropriate care plan for our members.
• Manage catastrophic members in the hospital by providing guidance to case managers, performing peer to peer review, deciding the appropriate care settings and promoting appropriate transitions of care.
• Document all communication and decision making clearly within health plan portal.
• Ensure appropriate service utilization and benefit administration by monitoring over- and underutilization
• Act as a liaison between the medical staff, utilization review and third party services to effectively promote the appropriate levels of medical care.
• Serve as medical expertise for utilization management; reviews and evaluates cases with review nurses.
• Serve as a physician member of the utilization management team.
• Participate in relevant health plan committees, including but not limited to credentialing, quality, UM meetings, staff meetings and joint work group meetings with delegated groups as directed by Medical Director.
• This position reports directly to the Senior Health Plan Medical Director.

Qualifications and Experience

• Minimum 5 years of clinical experience. Prefer specialty is internal medicine/hospitalist.
• MD or DO from a fully accredited university and residency program.
• 2-3 years experience in health plan, medical group or hospital utilization management position.
• Strong knowledge of medical and CMS regulations.
• Current, valid and unrestricted California Physician and Surgeon’s license with Board certification in one of the American Board of Medical Specialties (internal medicine preferred).
• Must be willing and eligible to apply for license in the following states and all future states that Health plan expands into: Arizona, Nevada, Florida, Texas and North Carolina. (licensure expenses will be paid for by company).
• Any Utilization Management related certification is a plus.
• Ability to build rapport with medical staff and management leadership to obtain necessary approvals of new strategies for utilization management.
• Knowledge of current medical literature, research methodology, healthcare delivery systems, healthcare financial/reimbursement issues, and medical staff organizations.
• Dedication to the delivery of high-quality, cost-effective, efficient patient care services.
• Excellent communication skills.
• Must have great attention to detail and discipline to complete workload within turn around time.
• Part time position will require at least 20 hours commitment.
• Remote position with occasional in-office meetings.