Positions Needed
- 2 Pediatricians (Board Certified and/or Family Medicine Physician, Board Certified)
- 1 Development Pediatrician (Board Certified)
- 1 Child and Adolescent Psychiatrist (Board Certified)
- 1 Physician Medicine and Rehabilitation Physician
- 1 Internal Medicine Physician (Board Certified)
This position is within the Quality Management Unit and involves conducting quality of care investigations. The role ensures member health and well-being through timely and thorough investigations of quality of care issues. Responsibilities include developing corrective action plans, making appropriate referrals to oversight agencies, and maintaining necessary documentation.
Responsibilities
- Conduct member-centric and systemic investigations.
- Develop vendor-specific corrective action plans.
- Make referrals to oversight and regulatory agencies.
- Participate in care concerns and member issues as assigned.
- Maintain comprehensive case records.
- Elevate cases and trend concerns to supervisors as needed.
Skills Required
- Critical thinking and decision-making skills.
- Technological proficiency, including databases and Microsoft Office.
- Professional report and letter writing.
- Research and analysis capabilities.
- Strong oral and written communication skills.
- Personal planning, organization, and time management.
- Medical chart review and nursing process knowledge.
- Ability to analyze problems and develop corrective action plans.
Schedule and Work Requirements
- Primarily remote work with potential in-person office requirements.
- Starting at 40 hours per week, with potential shift to as-needed basis.
- Cases assigned between 8 AM and 8 PM, including weekends and holidays.
- Detailed operational expectations to be provided during training.
Physician Responsibilities
- Serve as primary clinical reviewers and certify cases.
- Review assessments and supporting records.
- Document clinical recommendations using standardized processes.
- Evaluate complex needs and synthesize information from multiple sources.
- Complete assignments within 48 hours of case assignment.
Consultative Clinical Responsibilities
- Social workers, BCBAs, and occupational therapists available for consultation.
- Consultants do not serve as primary reviewers or certify cases.
Anticipated Volume
- Up to 20,000 cases during the first three months.
- Substantial demand for physician reviewers anticipated.
Anticipated Availability
- Case review and documentation may take 1-3 hours per case.
- Turnaround time is 48 hours, with potential extensions in extenuating circumstances.
Required Education for All Roles
Candidates must possess and maintain an active license and appropriate schooling to practice in the relevant field.
Physician/Pediatrician/Psychiatrist Requirements
- Board Certified with expertise in a medical specialty.
- MD or DO degree from a medical school.
Training and Requirements
- Complete specific training and follow standardized procedures.
- Identify potential conflicts of interest and respond promptly to requests.
- Familiarity with PEDI-CAT is required; training provided if needed.