Medical Director of Utilization Management
Posted on: November 22, 2022
This Jobot Job is hosted by: Ashley ElmAre you a fit? Easy Apply
now by clicking the "Apply Now" button and sending us your
resume.Salary: $180,000 - $240,000 per yearA bit about us:The
Medical Director will provide leadership and address process
improvement for utilization management and quality assurance
programs, working closely with the Director of Medical Management,
Manager Quality Assurance, CMO, and medical management staff.Why
join us?Career Advancement / Growth - We encourage and support the
professional growth of its employees by providing financial
assistance to further their education.Employee benefits include a
choice of HMOs or PPO plan, along with dental, vision, flexible
spending accounts, long-term disability insurance, life and
accident insurance.Job DetailsThe Medical Director will take a
leading role, with Director of Medical Management, in driving
Utilization Management policies, procedures, and operational
process improvement. In collaboration with the Manager of Quality
Assurance, the Medical Director will assume a significant role in
measured performance in specified incentive programs related to
quality, value, and patient care.This position reports directly to
the CMO, while the Director of Medical Management and Manager of
Quality Assurance will report up to this position. Principal Duties
- Oversees the Utilization Management program, including, but not
limited to, the ambulatory referral process, clinical decision
making, and operational process improvement.
- Review pediatric and adult referral requests, including the
management of tertiary and out of network authorization
- Support, collaborate and coordinate with Manager, Quality
Assurance in the development and implementation of activities to
optimize reporting of quality metrics such as HEDIS, P4P, CMS
- Support, collaborate and coordinate with Manager, Member &
Provider Services on health plan performance improvement
- Oversees the operations of California Child Services (CCS)
authorization carve outs, helping to identify CCS-eligible
conditions and opportunities for process improvement to optimize
CCS carve outs.
- Serve as Physician representative for performance improvement
on internal and external Committees.
- Participate in educational activities and webinars to keep up
to date with most current information related to performance
improvement programs, including HEDIS, P4P, 5-Stars, VIIP and other
payor programs as needed.
- Develop and implement teaching curriculum for primary care
providers (MD, PA, NP) related to performance improvement.
- Oversees concurrent review team.
- Participate in various committees.
- Collaborate with the Director of Medical Management on the UM
Work Plan, and Manager of Quality Assurance on the QM Work
- Reports Utilization Management and Quality Management
activities to the Chief Medical Officer.
- Collaborate with the CMO to engage network physicians with
regard to performance, cost, clinical appropriateness and
- Assists the CMO in analysis of clinical and financial data to
develop and refine management activities, investigate and define
sources of variation, and ensure conformance with standards and
- Collaborates with contracting, medical management, finance,
claims department, I.T/Business Intelligence, and Executive Team on
programs, projects and initiatives designed to improve the quality
of care provided to our members and address medical costs.
- Other duties as required from time-to-time to support and
achieve organization's mission and goals.Qualifications
- MD/DO degree with active California License required.
- 5 or more years of clinical practice.
- 2 or more years of utilization review.
- Familiarity with provider management principles.
- Experience and familiarity with Performance Improvement
programs and metrics preferred.
- Demonstrated effective interpersonal skills, and oral and
written communications skills.
- Medical business exposure as Medical Director of IPA, Health
Plan or Medical Group preferred.
- Board certification in specialty - Pediatrics or Family
- In-patient experience preferred.Interested in hearing more?
Easy Apply now by clicking the "Apply Now" button.
Keywords: Jobot, Westminster , Medical Director of Utilization Management, Executive , Westminster, California
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