Physician Reviewer (Remote)

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.

We are currently looking for a Physician Reviewer to join our growing team on a full time basis!

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.

Office Location:

Remote – flexible hours

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.
• Perform Peer-to-Peer case discussions with payer medical directors, PCP’s, hospitalists and specialists.
• The Physician Reviewer must maintain 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.
• Attend and participate as assigned quarterly UM, QM and Compliance Committee Meetings.
• Provide input on clinical content for specific programs.
• Evaluate potential quality of care concerns as assigned.
• Assist 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.
• The physician Reviewer must function within the virtual environment and be able to work individually, while working collaboratively with the clinical/medical management team.

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

tango provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. tango will make reasonable accommodations for qualified individuals with known disabilities unless doing so would result in an undue hardship.