Medical Director

Position Summary:

The medical director is responsible for actively participating and guiding 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). The goal of the medical director will cooperate with and support the other medical directors and the South UM team 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. Additionally, the medical director will work with medical management and network management teams to establish, develop, and maintain IPA provider relations via in-person meetings, formal and informal provider education, communication, and delivery of management services.

Essential Duties and Responsibilities include the following:

Prior Authorization:

• 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, participate in the pre-service medical necessity review of patient care.
• Review prior authorization requests for medical necessity with respect to Health Plans, CMS, third-party, (i.e., MCG, McKesson InterQual, American Imaging Management, and USPSTF), and medical group Medical Policies and Clinical Guidelines.
• Perform internet searches for other existing policies/guidelines/medical necessity indications for requested services in order to facilitate quality, cost-effective care.
• Identify high-risk patients and help coordinate care with the high-risk team.
• In collaboration with the Lead Medical Director may identify needs for and participate in the development and implementation of Utilization Management/ Care Management policies and procedures to promote cost-effectiveness quality medical care.
• Analyze and understand the major cost drivers related to the Cal MediConnect and Exchange populations, work with South UM team to target specific cost drivers (provider, process, or service), create corrective plans in driving down costs - educate/communicate with providers to implement changes in referral pattern, utilization, and management of patients, improve internal processes, study alternatives/new partnerships to provide better care.
• From time to time, meet with individual PCP or specialist or provider group to review best practices, authorization requests and denials, utilization metrics and outcomes.
• Participate/organize/chair UM team meetings to improve internal processes, team development and education.
• Work closely with high risk program Medical Director specific to Cal MediConnect members.
• Focus on Cal MediConnect and Exchange utilization management.
• Will also perform prior auth function for ADOC/OC campus as well as for other South campuses should need arise in cross coverage, secondary/tertiary review, or medical director decision making.
• Perform retro-claims review for outpatient and inpatient.
• Working with UM Director, participate, support, or take lead in audit processes both internal and external.
• May participate in health plan joint operations meetings for discussions related to UM.

Provider Relations:

• Work with network management team to establish and maintain provider relations.
• Work with NM to grow and retain membership, focusing on patient satisfaction and ensuring members receive highest quality care in the most efficient and cost effective manner.
• Travel and meet with IPA providers in their offices or at Town Halls to promote better relations, provide education and training, get feedback on the needs of the providers and their offices on medical management services, and implement changes to refine and grow network with ultimate goal to grow and retain membership.
• In conjunction with the CMO and Lead Medical Director, hold quarterly meetings with contracted PCPs and specialists regarding performance metrics.
• Identify "good" partners - specialists and PCPs who are aligned with our goals of Triple Aim.
• Assist in on-boarding new providers to the medical group on UM program, quality metrics, and network.
• Be a direct resource to the IPA providers on issues related to UM and other aspects of patient care.
• Understand contracts - PCP, specialists, ancillary providers, hospitals, and vendors.

Quality/Grievance and Appeals:

• Understand RMG/ADOC/Lakeside internal program for Q/G&A and from time to time, may review and respond to G&A and peer review.
• May be more narrowly focused to Cal MediConnect and Exchange population.
• Participate in meetings to review, develop, and continually improve internal QI/peer process and programs.
• May perform verbal counseling to IPA providers after G&A determinations for corrective action plans and follow ups.
• May write or review written counseling to IPA providers.

The pay range for this position at commencement of employment is expected to be between $200,000 - $300,000 annually; however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, licensure, skills, and experience.

The total compensation package for this position may also include other elements, including a sign-on bonus and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offered.

Details of participation in these benefit plans will be provided if an employee receives an offer of employment.

If hired, employee will be in an "at-will position" and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.

As one of the fastest growing Independent Physician Associations in Southern California, Regal Medical Group, Lakeside Community Healthcare & Affiliated Doctors of Orange County, offers a fast-paced, exciting, welcoming and supportive work environment. Opportunities abound, and enterprising, capable, focused people prosper with us. We promote teamwork, nurture learning, and encourage advancement for all of our employees. We want to see you excel, because we believe that your success is our success.

Full Time Position Benefits:

The success of any company depends on its employees. For us, employee satisfaction is crucial not only to the well-being of our organization, but also to the health and wellness of our members. As such, we are firmly dedicated to providing our employees the options and resources necessary for building security and maintaining a healthy balance between work and life.

Our dedication to our staff is evident in our comprehensive benefits package. We offer a very generous mixture of benefits, including many employer-paid options.

Health and Wellness:

• Employer-paid comprehensive medical, pharmacy, and dental for employees
• Vision insurance
• Zero co-payments for employed physician office visits
• Flexible Spending Account (FSA)
• Employer-Paid Life Insurance
• Employee Assistance Program (EAP)
• Behavioral Health Services

Savings and Retirement:

• 401k Retirement Savings Plan
• Income Protection Insurance

Other Benefits:

• Vacation Time
• Company celebrations
• Employee Assistance Program
• Employee Referral Bonus
• Tuition Reimbursement
• License Renewal CEU Cost Reimbursement Program
• Business-casual working environment
• Sick days
• Paid holidays
• Mileage

Employer will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of the LA City Fair Chance Initiative for Hiring Ordinance.

Education and / or Experience:

• Doctor of Medicine or Doctor of Osteopathic Medicine degree.
• Board certified, maintain board certification, active California license, and DEA privilege.
• Minimum of five years of prior clinical experience required, with at least two years of managed-care or health-plan experience preferred.
• Preference given to a candidate who has demonstrated excellence in both hospital based and outpatient medical practices.
• Must demonstrate a strong clinical fund of knowledge.
• Must have the ability to interpret and apply clinical guidelines and policies.
• Must have excellent communications skills both verbally and written.
• Must have strong organization skills
• Ability to work in a multi-task, fasting moving 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.
• Work as a member of the team.