Regional Medical Director

4 weeks ago


Auburn, California, 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, ensuring the cost-effective utilization of services, and promoting the highest level of quality care for our members.

Key Responsibilities
  • Perform Treatment Authorization Request (TAR) reviews and appeals to determine medical necessity and appropriateness of services, and review claims that are questionable in dollar amount or volume or scope of services.
  • Confer with and counsel participating physicians who have questionable patterns of utilization.
  • Coordinate with Utilization Management department managers and directors to provide daily support and direction to staff on issues pertaining to UM.
  • Assist in developing and revising policies to support utilization management activities, including criteria and guidelines for appropriate use of services, clinical practice guidelines, and treatment guidelines.
  • Serve on the Quality/Utilization Advisory Committee, Pharmacy & Therapeutics Committee, Credentials Committee, and Internal Quality Improvement Committee as requested by the Chief Medical Officer.
  • 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 the Partnership provider network to improve quality of care and member experience.
  • Perform Pharmacy Authorization reviews and appeals to determine medical necessity and appropriateness of prescribed medications.
  • Act as a liaison to the local medical community.
  • Perform other activities related to region assignment as assigned.
Qualifications

We are seeking a Medical Doctor or Doctor of Osteopathy with completion of a residency program and a minimum of 5 years post-residency clinical experience. The ideal candidate will have a California Medical License, Board Certification in an American Board of Medical Specialist Specialty, and a strong understanding of outpatient clinical practice and hospital medicine. Additionally, the candidate should have advanced computer skills, including proficiency in multiple software applications, and the ability to present data in a local and concise manner.

Work Environment and Physical Demands

The successful candidate will spend more than 50% of their work time in front of a computer monitor and must be able to work in a fast-paced environment while maintaining 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, and abide by the HealthPlan's policies and procedures.

Compensation

The hiring range for this position is $259,363.03.



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