Medical Director of Care Excellence
2 days ago
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.
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.
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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Auburn, California, United States Partnership HealthPlan of California Full timeAbout the RoleWe are seeking an experienced Medical Director to oversee care quality and appropriateness at Partnership HealthPlan of California. As a key leader, you will drive the effective utilization of services while maintaining cost-effectiveness.Key ResponsibilitiesLead reviews of Treatment Authorization Requests (TARs) to determine medical necessity...
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