Positions Needed
- 2 Pediatricians (Board Certified and/or Family Medicine Physician)
- 1 Development Pediatrician (Board Certified)
- 1 Physician Medicine and Rehabilitation Physician
- 1 Internal Medicine Physician (Board Certified)
This position reports within the Quality Management Unit and conducts quality of care investigations pursuant to the contract with the state health care system. The role involves investigating member-centric and systemic quality of care concerns to ensure member health and well-being. The position requires conducting timely, thorough investigations for all quality of care issues and implementing vendor-specific corrective action plans using a standardized process.
- Make appropriate referrals to oversight and regulatory agencies.
- Participate in care concerns, care needed today, and member issues as assigned.
- Maintain all necessary documentation to support case work.
- Request appropriate documentation for quality-of-care investigations and ensure maintenance of comprehensive case records to support allegation review and substantiation levels.
- Elevate cases and/or trend concerns to the supervisor as needed.
Skills Required
- Critical thinking and technological skills, including database use
- Proficiency in Microsoft Office products, email, and electronic referral and verification sources
- Ability to produce professional technical reports and letters
- Research and analytical skills
- Strong oral and written communication skills
- Personal planning, organization, and time management
- Medical chart review skills
- Understanding of the nursing process, including assessment, monitoring, and evaluation
- Decision-making skills
- Ability to critically analyze problems and develop effective plans for corrective action
Schedule and Work Requirements
- Remote work primarily, with occasional in-person office requirements
- Starting at 40 hours per week
- Case assignments anticipated between 8 AM and 8 PM
- Cases assigned any day of the week, including weekends and holidays
- Work may eventually shift to an as-needed basis
- Details about training, assignment timelines, shifts, and remote or hybrid arrangements will be provided
Physician Responsibilities
- Serve as primary clinical reviewers and certify cases
- Review assessments and available supporting records
- Consider information submitted by the member or health care decision-maker
- Seek discipline-specific consultation when needed
- Document a clear clinical recommendation and rationale using standardized processes and templates
- Evaluate complex needs, synthesize information from multiple sources, and document reasoning clearly
- Complete assignments within required timelines (48 hours from case assignment)
- Knowledge of pediatrics and adolescent and teenage development is essential
- Experience with developmental disabilities, complex medical or behavioral needs, and interdisciplinary review is valuable
Consultative Clinical Responsibilities
- Social workers, BCBAs, and occupational therapists available for expertise within their respective disciplines
- These roles will not serve as primary reviewers or certify cases
- No guarantee of a set number of consultations, assignments, or hours
Anticipated Volume
- Approximately up to 20,000 cases to be processed during the first three months
- Substantial demand for physician reviewers during implementation, potentially requiring full-time availability
Anticipate Availability
- Actual hours depend on case volume, staffing, and case readiness
- Each case may take 1-3 hours for review and documentation
- 48-hour turnaround time from receipt
- Additional time granted only in extenuating circumstances
- Additional time may be granted if records are needed or if communication with the health care decision-maker is required
Required Education for All Roles
Candidates must possess and maintain an active license and schooling to practice in the relevant field.
Physician/Pediatrician/Psychiatrist Requirements
- Board Certified completed additional requirements and passed an examination demonstrating expertise in a particular medical specialty
- Earned an MD or DO degree from medical school
Training and Requirements
- Comfortable with ECR-specific training, standardized review, and documentation procedures
- Identifying potential conflicts of interest
- Responding promptly to assignments and requests for clarification
- Familiarity with the PEDI-CAT is required, but training will be provided if needed