Inpatient Medical Director, West Coast

Role Overview

• Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit
• Provides medical leadership of utilization management, cost containment, and medical quality improvement activities
• Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality decision making
• Supports effective implementation of performance improvement initiatives for capitated providers
• Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members
• Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements
• Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership
• Conducts regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes
• Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals
• Participates in provider network development and new market expansion as appropriate
• Assists in the development and implementation of physician education with respect to clinical issues and policies
• Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components
• Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice to improve the quality and cost of care
• Interfaces with physicians and other providers to facilitate implementation of recommendations to improve utilization and health care quality
• Reviews claims involving complex, controversial, or unusual or new services to determine medical necessity and appropriate payment
• Develops alliances with the provider community through the development and implementation of medical management programs
• Represents the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues as needed
• Represents the business unit at appropriate state committees and other ad hoc committees
• May be required to work weekends and holidays as needed.

Requirements

• Medical Doctor or Doctor of Osteopathy
• Utilization Management experience and knowledge of quality accreditation standards preferred
• Actively practices medicine
• Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is advantageous
• Experience treating or managing care for a culturally diverse population preferred.

Benefits

• health insurance
• 401K and stock purchase plans
• tuition reimbursement
• paid time off plus holidays
• flexible approach to work with remote, hybrid, field or office work schedules