Medical Director, Medical Management

JOB SUMMARY: Responsible for Medical Management functions within the areas of inpatient and/or outpatient Utilization Management, Case Management, and Claim adjudication. Will apply medical judgement and pertinent evidence based clinical guidelines to determine medical necessity and length of stay on concurrent facility-based admissions, concurrent, and retroactive and claims reviews of medical services. Will adhere to regulation set by state, federal, and other regulatory managed care agencies and as the health plan’s contracts stipulate. Additionally, this position must work collaboratively with the Medical Services and Managed Service Organization (MSO) to process authorizations needing physician review within the required time frame. As part of a team, is expected to support colleagues and the team to meet medical management performance targets, the coordination of care with social work and mental health counseling, psycho-social support services, in-home support, legal services, skilled nursing, home health, etc. Assist with review of post-service claims for medical necessity.

ESSENTIAL JOB FUNCTIONS:

1. Responsible for UM functions for service authorization in accordance with regulatory standards set by ICE/Health Plan and other regulatory agencies.

2. Performs daily concurrent review, retro reviews, ER reviews, discharge planning, pre-certification/prior authorization request review and ensures patients meet appropriate level of care based on acceptable evidenced based practices.

3. Works collaboratively with Hospitalists, hospital partners, and care teams to provide whole person care that is focused on high quality in a cost effective manner.

4. Utilizes authorization matrix, ancillary rosters, DOFR, and/or delegation agreements to drive decision-making.

5. Maintains up to date knowledge of rules and regulations governing utilization management processes.

6. Performs Peer to Peer meetings.

7. Identify gaps in the IPA network and assist in identifying and recruiting new providers. Evaluates, maintains, and updates the preferred Regional network list of specialist, ancillary services, hospitals in collaboration with managed care.

8. Monitor utilization trends and communicate program outcomes to IPA leadership and physicians.

9. Will provide quality reviews that address the individual needs of the member, align with medical evidence guidelines, and meet compliance requirements.

10. Identifies and appropriately documents areas of inappropriate utilization of resources

11. Act as the main point of contact for physicians who wish to speak directly about authorization requests and follow up.

12. Attends and Participates in all team meetings and those assigned per management.

13. Maintains regular and consistent attendance.

14. Adheres to Compliance Plan and HIPAA regulations.

15. Position may be full time or part time.

16. Applicant may work on site, remote or in a hybrid version.

POSITION REQUIREMENTS:

• 3+ years of Health Plan or IPA experience doing UM Authorization Reviews
• 3+ years of experience with UM case review leading to a decision using Medi-Cal and Medicare guidelines
• 2+ years prior CMS plan experience
• 3+ years of experience using InterQual or MCG

LICENSURE/CERTIFICATE/TRAINING:

• Physician (MD or DO) with an active unencumbered license to practice medicine in California and Board Certification in Internal Medicine/ Family Medicine or Pediatrics. Meets all credentialing requirements per IHPC and IIC Credentialing policy. Additional licensure in Texas, Arizona, Utah or Nevada preferable
• Hospital / Nursing Home experience highly recommended
• At least 10 years’ experience post training, as a clinician