Medical Director of Care Excellence

2 days ago


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

Oversight of care quality and appropriateness is essential in our organization, Partnership HealthPlan of California. As a key leader, you will ensure the effective utilization of services while maintaining cost-effectiveness.

Key Responsibilities
  • Determine medical necessity and appropriateness of services through reviews of Treatment Authorization Requests (TARs), interpreting benefits and limitations.
  • Collaborate with physicians to identify questionable utilization patterns and develop policies to support utilization management activities.
  • Coordinate daily support and direction to staff within the Utilization Management department, working closely with managers and directors.
  • Serve on the 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.
  • Provide expertise to the Grievances and Appeals Department in preparing for and testifying in State Fair Hearings.
  • Foster engagement with the Partnership provider network to enhance quality of care and member experience.
  • Conduct Pharmacy Authorization reviews to determine medical necessity and appropriateness of prescribed medications.
  • Nurture relationships with local healthcare professionals.
Qualifications and Requirements

To be successful in this role, you must have a Medical Doctor or Doctor of Osteopathy degree, completed residency program, and at least 5 years of post-residency clinical experience.

Essential Requirements
  • A valid California Medical License.
  • Board Certification in an American Board of Medical Specialist Specialty.
  • In-depth understanding of outpatient clinical practice and hospital medicine.
  • A valid California drivers license and proof of current automobile insurance compliant with Partnership policy.
Working Conditions and Salary

This role requires more than 50% of work time spent in front of a computer monitor. You must be able to maintain courtesy and composure in a fast-paced environment. The estimated annual salary range is $259,563.60 - $363,389.03, reflecting your value as a senior physician leader.



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