Pediatric Nephrology Opening in California

Thank you for your interest in supporting Maximus and the California Department of Managed Healthcare Independent Medical Review project (CA DMHC IMR).

The staff supporting this project complete IMRs for requested health care services that have been denied by managed health care plans in CA. The clinical reviewer performing the IMR must be a medical professional and a clinical expert in the treatment of the enrollees medical condition, and knowledgeable about the proposed treatment through recent or current actual clinical experience treating patients with similar medical condition(s). Notwithstanding any other provision of law, the medical professional shall hold a non-restricted license in any state of the United States, and for physicians a current certification by a recognized American Medical Specialty Board in the area or areas appropriate to the condition or treatment under review. CA license is preferred.

Expert reviewers are 100% remote and reviewers will complete cases on their own computer. This is a 1099 Independent Contractor position. The cases are Medical Necessity or Experimental / Investigational reviews, and the reviewers must be unbiased and have no relationship with the managed health care plan, the requesting provider, or the enrollee.

Independent medical review cases can be one of three types : Medical Necessity, Experimental / Investigational, and Emergency Services. Payment is per case and varies based on both case type and specialty of the reviewer. A case typically takes two or more hours to complete. Standard medical necessity and standard experimental / investigational cases need to be completed within 7 days. Expedited medical necessity cases need to be completed within 24 hours. Expedited experimental / investigational cases need to be completed within 3 days.

The project team will provide project-specific training once the provider has completed the Maximus onboarding process.

Minimum Qualifications :

Active license

24 hours of direct patient care per week

Board Certification

5 years experience in appropriate specialty post-residency / fellowship training (MD / DO)

3 years experience in appropriate specialty post-training (non-MD / DO)

For behavioral health reviewers : experience with using LOCUS / CALOCUS and ASAM 4th edition.

California Department of Managed Healthcare (CA DMHC) :

RATE : Range $150-$400 per case

Description of Review : Depending on the Specialty and Type of Review Requested (Standard or Expedited)

A $300.00 new reviewer training bonus will be issued upon completion of the initial training.

The project will provide support when reviewers have questions / challenges.

The client may have inquiries regarding your reviews, and may ask for additional records to be reviewed, and / or additional issues to be addressed. Additional compensation for more time spent on work on a given case is handled on a case-by-case basis.

If you have any questions, please feel free to reach out at your convenience. Thank you for your support, we look forward to working with you!