Chief Medical Officer for Utilization Management

2 days ago


Auburn, California, United States Partnership HealthPlan of California Full time
About the Role

We 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 Responsibilities
  1. Lead reviews of Treatment Authorization Requests (TARs) to determine medical necessity and appropriateness of services, considering benefits and limitations.
  2. Collaborate with physicians to identify and address questionable utilization patterns, developing policies to support utilization management activities.
  3. Provide daily support and direction to staff within the Utilization Management department, working closely with managers and directors.
  4. Serve on the Quality/Utilization Advisory Committee, Pharmacy & Therapeutics Committee, Credentials Committee, and Internal Quality Improvement Committee.
  5. Ensure potential quality issues are reviewed and determined appropriate for review by the Peer Review Committee.
  6. Support the Grievances and Appeals Department in preparing for and testifying in State Fair Hearings.
  7. Foster engagement with the Partnership provider network to enhance quality of care and member experience.
  8. Conduct Pharmacy Authorization reviews to determine medical necessity and appropriateness of prescribed medications.
  9. Maintain relationships with local healthcare professionals.
Qualifications and Requirements

For this role, we require a Medical Doctor or Doctor of Osteopathy degree, completed residency program, and at least 5 years of post-residency clinical experience.

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

The estimated annual salary range for this role is $259,563.60 - $363,389.03. This position requires spending more than 50% of work time in front of a computer monitor. We expect you to maintain courtesy and composure in a fast-paced environment.



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