Physician Reviewer (Remote)

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.

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

Office Location

Remote – flexible hours.
Must be licensed in OR and/or TN.

Essential Functions

• Perform focused real‑time case reviews by reviewing the information in the software system(s).
• Apply medical judgement and pertinent evidence‑based clinical guidelines to determine medical necessity on pre‑service, concurrent, retroactive and claims reviews of medical home health services.
• Review Potential Quality Issues (PQIs).
• Provide quality reviews that address the individual needs of the member, align with medical evidence guidelines, and meet compliance requirements.
• Identify and appropriately document areas of inappropriate utilization of resources.
• Participate in inter‑rater review cases.
• Perform Peer‑to‑Peer case discussions with payer medical directors, PCPs, hospitalists and specialists.
• Maintain positive relationships with a variety of external and internal stakeholders, including primary care physicians, specialists, hospitalist physicians, nursing, therapists, and staff; participate in interdisciplinary team meetings.
• Provide 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 in 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.
• Identify 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.
• Interface with physicians and other providers to facilitate implementation of recommendations 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.
• Function within the virtual environment and be able to work individually while collaborating with the clinical/medical management team.

Qualifications

• MD or DO license in good standing and no restrictions in the state where UM reviews are conducted.
• Board certified – preferable in a primary care specialty (Internal Medicine, Gerontology, Family Medicine, Physical Medicine and Rehabilitation).
• Actively practicing physician with 10+ years’ practice.
• Coursework in 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.
• Experience with Medicare Advantage, Medicare and Medicaid.
• Proficient computer and technology skills.
• CMS Chapter 7 Home Health knowledge is a plus.
• Support for a culture of continuous quality improvement.
• 2+ years of 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.