Outpatient Medical Director
3 weeks ago
REMOTE
MUST BE CURRENTLY WORKING FOR A HEALTH PLAN
JOB DESCRIPTION
The Outpatient Medical Director is responsible for actively participating in the review process of pre-service requests for services, and to follow guidelines in the approval of those services or in making recommendations for other determinations to the provider/vendor (denial/modification/redirection). Additionally, the role will cooperate with and support the other physician reviewers, nurses and Medical Directors by knowing all processes and procedures, while working to deliver excellent care in a cost-effective manner based on medical management referral processing guidelines. The Medical Director will be detail-oriented and able to research and successfully evaluate often-complex clinical information to help formulate decisions and communication with members, providers and internal users. The position will connect the prior authorization process to overall performance of the provider network, actively engaging and aligning the network to support The Triple Aim.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
Understand, promote and manage with the principles of medical management to facilitate the right care at the right time in the right setting.
As part of a team of medical directors, nurses and coordinators, participates in the pre-service medical necessity review of patient care.
Reviews prior authorization requests for medical necessity with respect to Health Plans, CMS, third-party guidelines (i.e., McKesson InterQual, American Imaging Management, USPSTF) and medical group Medical Policies and Clinical Guidelines.
Does internet searches for other existing policies/guidelines/medical necessity indications for requested services in order to facilitate quality, cost-effective care.
Uses individual service requests, and larger scale analytics to identify outlier trends in utilization patterns; the successful candidate will be fluent in these diagnostics and be able to effectively engage and align the provider network to improve overall performance and patient-centered outcomes.
Identify high-risk patients and help coordinate care with the high-risk team.
In collaboration with the Medical Director may identify needs for and participates in the development and implementation of Care Management/Utilization Management policies and procedures to promote cost-effectiveness quality medical care.
Participates in peer-to-peer discussions with providers to discuss service request decisions as well as elective care plans for member.
Liaises with the appeals and grievances department and Health Plan Medical Directors when adverse determinations come under discussion.
EDUCATION AND/OR EXPERIENCE:
Doctor of Medicine degree.
Specialty training and/or managed care experience preferred.
A minimum of five years of prior clinical experience required, with at least two years of managed-care or health-plan experience preferred.
Must demonstrate a strong clinical fund of knowledge.
Must have familiarity with the principles of clinical research and have the ability to interpret and apply clinical guidelines and policies.
Strong proficiency in MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point) and ability to conduct research over the internet.
Must have excellent communications skills both verbally and written.
Ability to deal with responsibility with confidential matters.
Must have strong organizational skills.
Ability to work in a multi-task, high stress environment.
Must be able to handle multiple projects at one time, reset priorities day-to-day to meet deadlines, and know when to ask for assistance and direction when working with conflicting priorities.
Must be self-motivated, self-guiding, driven, and have high personal ethics.
Must have the ability to work with all levels of management and have the ability to develop positive working relationships with medical directors and company department heads.
#CARE6
-
Nephrology Medical Director
4 weeks ago
Northridge, California, United States Regal Medical Group Full timeJob Title: Nephrology Medical DirectorRegal Medical Group is seeking a highly skilled Nephrology Medical Director to lead our Renal Services team. As a key member of our organization, you will be responsible for managing patients with chronic kidney disease (CKD) and those on renal replacement therapy (RRT).Key Responsibilities:Develop and implement best...
-
Medical Director, Renal Services
7 days ago
Northridge, United States Regal Medical Group Full timeJob DescriptionPosition Summary: The Medical Director of Renal Services will be a nephrology-trained physician that works in dyad partnership with the Director of Renal Services to manage our patients with chronic kidney disease (CKD) across Lakeside, Regal and Affiliated Doctors of Orange County (ADOC) medical groups. Our renal disease-management program...
-
Medical Director Opportunity in Los Angeles
3 weeks ago
Northridge, California, United States Britt Medical Search Full timeMedical Director Opportunity in Los AngelesWe are seeking a highly skilled Medical Director to join our team in Los Angeles, California. As a Medical Director, you will be responsible for leading our primary care team and providing exceptional patient care.About the RoleThis is a full-time position that will be located in Los Angeles, CA. You will be working...
-
Coordinator, Outpatient
5 months ago
Northridge, United States Regal Medical Group Full timeJob DescriptionPosition Summary:The Outpatient Coordinator is responsible for managing and coordinating care for high risk patients. The Outpatient Coordinator will assist case managers in developing a comprehensive care plan for high risk patients. This individual will facilitate appointments for the member, which include Health Plan Programs related to...
-
Outpatient Case Manager Lead
4 days ago
Northridge, United States Regal Medical Group, Inc. Full timestrong>Job DescriptionPosition Summary:The Case Manager Outpatient RN Lead is responsible for the assessment, treatment, planning, intervention, monitoring, evaluation and documentation on identified RMG/LMG members. The Case Manager Outpatient RN Lead will educate and assist staff in developing a plan of care in collaboration with the Primary Care...
-
Outpatient Case Manager Lead
2 weeks ago
Northridge, United States Regal Medical Group, Inc. Full timeJob DescriptionPosition Summary:The Case Manager Outpatient RN Lead is responsible for the assessment, treatment, planning, intervention, monitoring, evaluation and documentation on identified RMG/LMG members. The Case Manager Outpatient RN Lead will educate and assist staff in developing a plan of care in collaboration with the Primary Care Physician,...
-
SLP - Outpatient
2 weeks ago
Northridge, United States Northridge Hospital Medical Center Full timeDetailsClient Name Northridge Hospital Medical Center Job Type Travel Offering Allied Profession SLP Specialty Outpatient Job ID 29112228 Job Title SLP - Outpatient Weekly Pay $2058.5 Shift DetailsShift 8H Days Scheduled Hours 40 Job Order DetailsStart Date 11/04/2024 End Date 02/03/2025 Duration 13 Week(s) Client DetailsAddress 18300 Roscoe Blvd City...
-
Medical Director
3 weeks ago
Northridge, California, United States Dignity Health Full timeOverviewDignity Health - Northridge Hospital Medical Center is a leading provider of compassionate, high-quality, and affordable patient-centered care. As a part of Dignity Health, one of the nation's five largest health care systems, we share a rich legacy of delivering exceptional care to our community. Our hospital offers a full complement of...
-
Outpatient Case Manager RN Position
3 weeks ago
Northridge, California, United States Regal Medical Group Full timeJob Summary:The Outpatient Case Manager RN is responsible for the assessment, treatment planning, intervention, monitoring, evaluation, and documentation of identified High Risk members.Collaborating with the admitting, attending, and consulting physician, the member, and other healthcare practitioners, the Case Manager Outpatient RN assesses and develops a...
-
Outpatient Case Manager
4 weeks ago
Northridge, California, United States Regal Medical Group Full timeJob SummaryThe Outpatient Case Manager is a critical member of our healthcare team, responsible for coordinating and managing the care of high-risk patients in an outpatient setting. This role requires a strong clinical background, excellent communication skills, and the ability to work effectively with patients, families, and healthcare providers.The ideal...
-
Outpatient Care Coordinator
3 weeks ago
Northridge, California, United States Regal Medical Group Full timeJob Summary:The Outpatient Care Coordinator will be responsible for managing and coordinating care for high-risk patients. This role will assist case managers in developing comprehensive care plans for high-risk patients, ensuring timely and effective care delivery.Key Responsibilities:Assist case managers in developing and implementing care plans for...
-
Outpatient Case Manager RN Position
3 weeks ago
Northridge, California, United States Regal Medical Group Full timeJob DescriptionThe Outpatient Case Manager RN is responsible for assessing, planning, implementing, and evaluating the care of high-risk members in an outpatient setting.This role involves collaborating with physicians, healthcare practitioners, and other stakeholders to develop and implement care plans that meet the unique needs of each member.The ideal...
-
Outpatient Case Manager RN
2 weeks ago
Northridge, United States Regal Medical Group, Inc. Full timeJob DescriptionPosition Summary:The Outpatient Case Manager is responsible for the assessment, treatment planning, intervention, monitoring, evaluation and documentation on identified High Risk members. The Outpatient Case Manager will assess and develop a care plan in collaboration with the admitting, attending and consulting physician, the member and other...
-
Medical Denial Specialist
4 weeks ago
Northridge, California, United States Regal Medical Group Full timeJob SummaryThe Denial Nurse is a critical member of our team, responsible for preparing and maintaining health plan criteria for our campus Medical Directors. This role requires collaboration with health plans to obtain updated criteria, ensuring that our staff provides a level of patient services that meets or exceeds our expectations.Key...
-
Outpatient Case Manager RN Position
3 weeks ago
Northridge, California, United States Regal Medical Group Full timeJob SummaryThe Outpatient Case Manager RN is responsible for assessing, planning, implementing, and evaluating the care of high-risk members. This role requires collaboration with physicians, members, and other healthcare practitioners to ensure the appropriate level of care is provided and to prevent hospital admissions and readmissions.Key...
-
Outpatient Case Manager
2 weeks ago
Northridge, United States Regal Medical Group, Inc. Full timeJob DescriptionPosition Summary:The Outpatient Case Manager is responsible for the assessment, treatment planning, intervention, monitoring, evaluation and documentation on identified High Risk members. The Outpatient Case Manager will assess and develop a care plan in collaboration with the admitting, attending and consulting physician, the member and other...
-
Outpatient Case Manager TEMP RN
2 weeks ago
Northridge, United States Regal Medical Group, Inc. Full timeJob DescriptionPosition Summary:The Case Manager Outpatient RN is responsible for the assessment, treatment planning, intervention, monitoring, evaluation and documentation on identified High Risk members. The Case Manager Outpatient RN will assess and develop a care plan in collaboration with the admitting, attending and consulting physician, the member and...
-
Outpatient Case Manager
2 weeks ago
Northridge, United States Regal Medical Group, Inc. Full timeJob DescriptionPosition Summary:The Outpatient Case Manager is responsible for the assessment, treatment planning, intervention, monitoring, evaluation and documentation on identified High Risk members. The Outpatient Case Manager will assess and develop a care plan in collaboration with the admitting, attending and consulting physician, the member and other...
-
Clinic Medical Director Full Time Physician
21 hours ago
Northridge, United States Tarzana Treatment Centers Full timeTarzana Treatment Centers, a leading provider of integrated health care services, is currently hiring for a Full-time Primary Care Clinic Director to oversee clinic operations at our Northridge, Lancaster and Tarzana locations. This position is responsible for the day-to-day management of 3 primary care clinics which integrate with behavioral health care....
-
Northridge, California, United States Curative Full timeAbout the OpportunityCurative is seeking a highly skilled Medical Director to lead our HEDIS and Quality Measures initiatives in Los Angeles. As a key member of our leadership team, you will be responsible for advancing health initiatives and providing superb Value-Based Care to diverse communities.Key ResponsibilitiesDevelop and implement HEDIS and STAR...
