Physician Reviewer

Brief Description

tango is a leader in the home health management industry and is preparing for significant growth. Our mission is to deliver innovative, home-based, post-acute solutions through proprietary technology and proven processes. We partner with health plans to provide a comprehensive suite of products and services designed to manage the total cost of care.

About the role

The Physician Reviewer is in a utilization management reviewer role at tango – providing UM case reviews, peer to peer calls/conversations and consultations in real-time; assisting as a resource with functional areas such as utilization management/review, provider relations and communications, and working with physicians to provide education, peer to peer reviews and support.

Essential Functions

• Perform focused real-time case reviews by reviewing the information in the software system(s).
• Applies medical judgement and pertinent evidence based clinical guidelines to determine medical necessity on pre-service, concurrent, and retroactive and claims reviews of medical home health services.
• Reviews Potential Quality Issues (PQIs).
• The Physician Reviewer will provide quality reviews that address the individual needs of the member, align with medical evidence guidelines, and meet compliance requirements.
• The Physician Reviewer will identify and appropriately document areas of inappropriate utilization of resources.
• Participates in inter-rater review cases.
• Performs Peer-to-Peer case discussions with payer medical directors, PCP’s, hospitalists and specialists.
• Maintains positive relationships with a variety of external and internal stakeholders, including working closely with primary care physicians, specialists, hospitalist physicians, nursing, therapists, and staff, participate in interdisciplinary team meetings.
• Provides medical guidance and review activities for home health utilization management and medical quality improvement activities and programs in accordance with health plan, regulatory, state, corporate, and NCQA accreditation requirements.
• Attends and participates as assigned quarterly UM, QM and Compliance Committee Meetings.
• Provides input on clinical content for specific programs.
• Evaluates potential quality of care concerns as assigned.
• Affords assistance in developing and reviewing policies as requested/needed.
• Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice and/or return to acute (RTA’s) to improve the quality and cost of care.
• Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality for home care services.
• Participate in all aspects of regulatory compliance related to health services functions at tango.

Qualifications

• MD or DO license in good standing and no restrictions in state where UM reviews are conducted.
• Board certified preferable in a primary care specialty (Internal Medicine, gerontology, Family Medicine, Physical Medicine and Rehabilitation).
• Must be an actively practicing physician with 10+ years’ practice.
• Course work in the areas of Health Administration, Health Financing and Insurance is helpful.
• Board Certification through American Board Medical Specialties.
• Knowledge and Experience: 3+ years of health plan or IPA experience conducting UM Authorization and determination reviews preferred.
• Peer-to-Peer meeting experience.
• Medicare Advantage, Medicare and Medicaid experience.
• Must be proficient and have good computer and technology skills.
• CMS Chapter 7 Home Health knowledge is a plus.
• Supports a culture of continuous quality improvement.
• 2+ years Milliman Care Guidelines or InterQual experience.

Skills

None specified in the job posting.

Benefits

None specified in the job posting.

Pay

Not specified in the job posting.

Schedule

Remote – flexible hours.