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MEDICAL DIRECTOR UTILIZATION MANAGEMENT - HOAG CLINIC

Department:  Physician
Status:  Full Time
Shift:  1st

Job Summary: 

The UM Medical Director is responsible or in part, for the overall quality, effectiveness and coordination of the medical review services of the Utilization Management Team of Hoag Clinic. Performs Utilization Management reviews, Conducts Peer to Peer Dialogues with providers and other Medical Directors, participate in other aspects of the utilization review activities and participates in the Quality Improvement programs for the Hoag Clinic.

 

The Medical Director also provides/assists in the direction and overall development and implementation of policies, procedures and clinical criteria or policies for all medical programs and services. The Medical Director will serve as a liaison between Hoag Clinic, providers, and other medical service entities in selected situations. Will also collaborate with the other Medical Directors and clinical, nursing and non-clinical leadership staff across the organization. The role will report directly with the Chief Clinical Officer and works with the Director of Medical Management in the over all oversight of the Utilization Management Team.

 

 

Essential Functions: 

Essential Functions:

  • Performs utilization management reviews for various types of requests which includes but not limited to medical/surgical services, mental health, admission review, home health care, SNF, LTAC and other acute inpatient rehabilitation services
  • Provides key leadership to clinical programs and works with senior leadership to promote the vision of the organization.
  • Participates with executive leadership to develop initiatives and protocols that impact operations.
  • Provides clinical oversight to all ambulatory services and manages the clinical leadership team of physicians.
  • Supervises the inter-agency clinical initiatives as needed.
  • Responsible for quality monitoring and quality improvement programs and clinical initiatives.
  • Responsible for recruitment and discipline of clinicians. Also, operational activities related to direct patient care, patient safety and risk management activities.
  • Develops and implements new programs in clinical departments
  • Executive leadership to care improvement teams
  • Works with finance and operational teams to develop workflows that provide quality and best patient experiences
  • Provides resources and support over-all strategy to provide meaningful population health and care management
  • Participates in EMR development as appropriate
  • Initiates and facilitates medical management related operations to ensure high quality patient care
  • Provides leadership to utilization management team to ensure cost effective and high – quality medical care
  • Works collaboratively across the organization to ensure overall business objectives are met
  • Supports compliance with regulatory standards and requirements from CMS, NCQA, URAC, state / federal and Health plan partners
  • Participation in Training regarding URAC, NCQA, Regulatory Compliance, Confidentiality, Conflict of Interest, HIPAA, and department specific training as applicable
  • Other duties as assigned.

 

 

Education, Training and Experience

 

Required

  • Registered Physician (MD/DO) in the State of California
  • At least 5 years of Direct Patient care
  • At least 2 years of Medical Director Experience in a Medical Group, Hospital, Health Plan or Risk Based MSO setting.
  • Experience with Medicare/Medicare Advantage Plans, Commercial Plans,  HMO, and/or Medi-Cal/ACA standards

 

Preferred:

  • Medical Director in a Utilization Management or Care Management Team

 

Skills or Other Qualifications

 

Required:

  • Demonstrate the strong analytic and clinical skills necessary to assess reports and medical records.
  • Proficient in computer and Microsoft Office Software skills especially Excel.

 

License and Certifications

Required: MD/DO

Preferred: N/A

 

*We are excepting interest for both Full-Time and Part-Time opportunities.

 


Nearest Major Market: Orange County
Nearest Secondary Market: Los Angeles

Job Segment: Medical, Rehabilitation, Clinic, Manager, Law, Healthcare, Management, Legal

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