Heritage Sierra Medical Group
Physician Reviewer (California Licensed) - Remote
Heritage Sierra Medical Group, Lancaster, California, us, 93586
Responsibilities
Review approximately
20 prior authorization (auth) requests daily , Monday-Friday.
Complete all reviews and submit them to the UM Coordinator
before 3:00 PM PST .
Evaluate each auth by reviewing:
Member's medical records
Auth request details
Relevant clinical criteria (CMS, Health Plan, InterQual, MCG)
For
denied or partially approved requests , provide:
A clear, detailed rationale
Cited criteria including name, title, and number
Monitor your assigned auth queue in the UM system.
Ensure that all auths are reviewed and returned within the assigned turnaround times (TAT), color-coded as:
Red:
Past due
Yellow:
Nearing deadline
Green:
Over 24 hours remaining
Notify the team in advance for
scheduled time off ; unreviewed auths must be carried over and completed the following day.
Provide
24-hour notice for unscheduled time off , when possible.
Collaborate with the UM team and follow protocols for criteria application and review submission.
Training Provided
Training on our Prior Authorization system and workflow
Instruction on how to cite criteria appropriately
Criteria documents will be attached to each auth for your review
Additional Notes
This is a
remote, part-time contract role
Reviewers are expected to consistently meet the
20-auths-per-day quota
Queue monitoring and daily communication with the UM team are essential for success.
The pay range for this position at commencement of contract is expected to be between $6,000.00 - $6,000.00 per month.
Active, unrestricted California medical license
(MD or DO)
Strong clinical decision-making and documentation skills
Familiarity with CMS guidelines, InterQual, MCG, and major health plan criteria
Ability to work independently and meet strict daily deadlines
Comfortable working with digital systems and remote teams
#J-18808-Ljbffr
Review approximately
20 prior authorization (auth) requests daily , Monday-Friday.
Complete all reviews and submit them to the UM Coordinator
before 3:00 PM PST .
Evaluate each auth by reviewing:
Member's medical records
Auth request details
Relevant clinical criteria (CMS, Health Plan, InterQual, MCG)
For
denied or partially approved requests , provide:
A clear, detailed rationale
Cited criteria including name, title, and number
Monitor your assigned auth queue in the UM system.
Ensure that all auths are reviewed and returned within the assigned turnaround times (TAT), color-coded as:
Red:
Past due
Yellow:
Nearing deadline
Green:
Over 24 hours remaining
Notify the team in advance for
scheduled time off ; unreviewed auths must be carried over and completed the following day.
Provide
24-hour notice for unscheduled time off , when possible.
Collaborate with the UM team and follow protocols for criteria application and review submission.
Training Provided
Training on our Prior Authorization system and workflow
Instruction on how to cite criteria appropriately
Criteria documents will be attached to each auth for your review
Additional Notes
This is a
remote, part-time contract role
Reviewers are expected to consistently meet the
20-auths-per-day quota
Queue monitoring and daily communication with the UM team are essential for success.
The pay range for this position at commencement of contract is expected to be between $6,000.00 - $6,000.00 per month.
Active, unrestricted California medical license
(MD or DO)
Strong clinical decision-making and documentation skills
Familiarity with CMS guidelines, InterQual, MCG, and major health plan criteria
Ability to work independently and meet strict daily deadlines
Comfortable working with digital systems and remote teams
#J-18808-Ljbffr