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Physician - Emergency Medicine - Medical Director, Outpatient (Orange, CA)

Company: Regal Medical Group
Location: Orange
Posted on: May 3, 2021

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 include the following:





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.
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.
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 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.


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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