Physician - Emergency Medicine - Medical Director, Outpatient (Orange, CA)
Company: Regal Medical Group
Posted on: May 3, 2021
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
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 include the following:
Understand, promote and manage with the principles of medical
management to facilitate the right care at the right time in the
As part of a team of medical directors, nurses and coordinators,
participates in the pre-service medical necessity review of patient
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
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
Liaises with the appeals and grievances department and Health Plan
Medical Directors when adverse determinations come under
Education and/or Experience:
Doctor of Medicine degree.
Specialty training and/or managed care experience preferred.
Minimum of five years of prior clinical experience required, with
at least two years of managed-care or health-plan experience
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
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
Typing 50 words per minutes with accuracy.
Ability to deal with responsibility with confidential matters.
Must have strong organization 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
Must be self-motivated, self-guiding, driven, and have high
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.
PandoLogic.Category: Healthcare, Keywords: Medical Director
Keywords: Regal Medical Group, Orange , Physician - Emergency Medicine - Medical Director, Outpatient (Orange, CA), Healthcare , Orange, California
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