Regional Medical Director

6 days ago


Auburn, Alabama, United States Partnership HealthPlan of California Full time
Job Summary

We are seeking a highly skilled and experienced Regional Medical Director to join our team at Partnership HealthPlan of California. As a key member of our leadership team, you will be responsible for overseeing the quality and appropriateness of care delivered through our organization.

Key Responsibilities
  • Perform Treatment Authorization Request (TAR) review and appeals to determine medical necessity and appropriateness of services.
  • Confer with and counsel participating physicians on questionable patterns of utilization.
  • Coordinate with Utilization Management department managers and directors to provide daily support and direction to staff.
  • Assist in developing and revising policies to support utilization management activities.
  • Serve on Quality/Utilization Advisory Committee, Pharmacy & Therapeutics Committee, Credentials Committee, and Internal Quality Improvement Committee.
  • Review potential quality issues and determine their appropriateness for review by the Peer Review Committee.
  • Advise the Grievances and Appeals Department on preparing for and testifying in State Fair Hearings.
  • Engage with the Partnership provider network to improve quality of care and member experience.
  • Perform Pharmacy Authorization review and appeals to determine medical necessity and appropriateness of prescribed medications.
Requirements
  • Medical Doctor or Doctor of Osteopathy degree, plus completion of a residency program.
  • Minimum of 5 years post-residency clinical experience.
  • California Medical License and Board Certification in an American Board of Medical Specialist Specialty.
  • Understanding of outpatient clinical practice and hospital medicine.
  • Valid California driver's license and proof of current automobile insurance compliant with Partnership policy.
Performance Based Competencies
  • Advanced computer skills, including proficiency in multiple software applications.
  • Ability to present data in a local, concise manner.
  • Ability to analyze complex medical issues.
Work Environment and Physical Demands

More than 50% of work time is spent in front of a computer monitor. Must be able to work in a fast-paced environment and maintain courtesy and composure.

All HealthPlan employees are expected to:

  • Provide the highest possible level of service to clients.
  • Promote teamwork and cooperative effort among employees.
  • Maintain safe practices.
  • Abide by the HealthPlan's policies and procedures.

Hiring Range: $259,563.60 - $363,389.03



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