Washington Permanente Medical Group announces the opening of a 0.6 FTE PhD Clinical Reviewer positions for Behavioral Health Access. Behavioral health physician reviewers 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. Meets 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 inpatient, residential, partial hospital, intensive outpatient, and acute outpatient facilities. Work with BH hospital liaisons in managing review of hospital admissions, transfers, discharges. Understanding of appropriate levels of care including inpatient, residential, partial hospital, intensive outpatient, and acute outpatient.
- Able to work well with other health professionals (BH hospital liaisons, BH case coordinators) to effectively facilitate appropriate level of care for Kaiser Permanente patients in a variety of care settings.
- Engage in collegial and respectful discussions 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.