MSO PHYSICIAN REVIEWER

About the role

The MSO Physician Reviewer is responsible for ensuring the appropriate utilization of healthcare services while maintaining high standards of patient care. This role involves conducting evidence-based medical necessity reviews for inpatient and outpatient services, assessing prior authorization requests, and supporting appeals and grievance processes.

Responsibilities

• Evaluate medical necessity, appropriateness, and efficiency of healthcare services using evidence-based criteria (e.g., MCG, CMS, and NCQA guidelines).
• Review and assess prior authorization requests for procedures, hospital admissions, specialty referrals, and medications.
• Provide peer-to-peer consultations with treating physicians to discuss medical necessity determinations and alternative treatment options.
• Participate in the appeals and grievance process by reviewing denied claims and reconsidering medical necessity based on additional documentation.
• Conduct retrospective and concurrent reviews of medical records to ensure accurate risk stratification and appropriate coding and documentation based on patient complexity.
• Analyze Hierarchical Condition Category (HCC) coding and Risk Adjustment Factor (RAF) scores to identify documentation gaps and ensure alignment with CMS risk adjustment models.
• Support provider education on proper documentation and coding practices to reflect complete and accurate disease burden and clinical acuity.
• Participate in chart reviews and audits to ensure compliance with risk adjustment methodologies and HCC coding.
• Review and analyze clinical data to support performance improvement projects and accreditation requirements.
• Collaborate with clinical and operational leadership to develop protocols and guidelines that enhance patient safety and care quality.
• Support efforts to reduce readmissions and enhance patient outcomes through evidence-based interventions.
• Participate in quality improvement initiatives, such as identifying trends in over- or underutilization, gaps in care, or process inefficiencies.

Requirements

• Medical Degree (MD or DO) from an accredited institution.
• Board Certification in a relevant specialty (Internal Medicine, Family Medicine, Emergency Medicine, or another applicable field).
• Active and unrestricted medical license in California.
• Minimum of 3-5 years of clinical experience; prior experience in utilization management, case review, HCC, risk adjustment, or managed care is preferred.
• Knowledge of medical necessity criteria, healthcare regulations, and payer policies (Medicare, Medicaid, and/or commercial insurance).
• Familiarity with UM guidelines (MCG, InterQual, CMS, NCQA, URAC) and utilization review process.
• Experience conducting peer-to-peer reviews and provider education sessions.
• Strong understanding of risk adjustment methodologies (e.g. HCC coding and RAF scoring) preferred.
• Knowledge of value-based care models, population health management, and healthcare cost containment strategies.
• Supervisory experience in a healthcare setting a plus.

Qualifications

• Must be able to fluently speak, read and write English.
• Fluency in Chinese (Cantonese and/or Mandarin) preferred.
• Fluency in other languages are an asset.