Medical Director - Memorial Health Services
LONG BEACH, CA 90745
About the Job
Location: Fountain Valley
Department: Utilization Management
Status: Full - time
Shift: Day
Pay Range*: $283,316.80 / annual - $424,964.80 / annual
At MemorialCare Health System, we believe in providing extraordinary healthcare to our communities and an exceptional working environment for our employees. Memorial Care stands for excellence in Healthcare. Across our family of medical centers, we support each one of our bright, talented employees in reaching the highest levels of professional development, contribution, collaboration and accountability. Whatever your role and whatever expertise you bring, we are dedicated to helping you achieve your full potential in an environment of respect, innovation and teamwork.
Position Summary
The Medical Director will provide medical oversight, expertise, and leadership to ensure the delivery of cost-effective, quality healthcare services PHP members:
The UM Medical Director serves as the medical expert for Utilization Management within the organization in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements. The Medical Director provides utilization reviews and consult with internal medical directors and physicians as needed to discuss optimal methods of treatment for specific diagnoses and conditions emphasizing evidence-based medicine and alternative levels of care. The Medical Director applies national evidence-based guidelines for medical necessity decision making on continued stay review, clinical compliance and quality issue or trend identification and medical review of complex, controversial, or experimental medical services. The Medical Director will assist in the development and implementation of new department policy as well as educates and interacts with physicians within the organization regarding utilization practices, guideline usage, pharmacy utilization and effective resource management.
Essential Functions and Responsibilities of the Job
- Perform Peer-to-Peer case discussions with payer medical directors
- Participates in telephonic outreach for collaboration with treating providers that includes discussion of evidenced based guidelines, opportunities to close clinical quality/service gaps, and care plan changes that can impact health care utilization
- Perform focused real-time and post-discharge hospital case reviews in hospital's EMR
- Identify areas of process improvements and inefficiencies
- Provide education for internal staff and providers on the needs of populations being served, when needed.
- Provide clinical input to accreditation team and regulatory compliance.
- Serve as a mentor, role model and coach for ongoing staff development.
- Perform related duties and projects as assigned
*Placement in the pay range is based on multiple factors including, but not limited to, relevant years of experience and qualifications. In addition to base pay, there may be additional compensation available for this role, including but not limited to, shift differentials, extra shift incentives, and bonus opportunities. Health and wellness is our passion at MemorialCare-that includes taking good care of employees and their dependents. We offer high quality health insurance plan options, so you can select the best choice for your family. And there's more... Check out our MemorialCare Benefits for more information about our Benefits and Rewards.
- Active and unrestricted State (CA) Medical License, free of sanctions from Medicaid or Medicare (MD or DO)
- Minimum of 12 years of relevant experience required; including a minimum of 5 years managed care experience, and 5 years leading and managing staff and minimum of 1 year of experience with clinical case reviews for medical necessity.
- Prior health plan experience, specifically in HMO/Managed Care including Utilization and/or Quality Program management.
- Clinical work in Internal Medicine, Family Practice, Pediatrics, or emergency Medicine
- Understanding of the California healthcare payors
- Experience demonstrating strong management and communication skills, consensus building and collaborative ability, and financial acumen.
- Knowledge of applicable state, federal and third-party regulations
Preferred Experience
- Peer Review, medical policy/procedure development, provider contracting experience.
- Experience with NCQA, HEDIS, Medicaid, Medicare and Pharmacy benefit management, Group/IPA practice, capitation, HMO regulations, managed healthcare systems, quality improvement, medical utilization management, risk management, risk adjustment, disease management, and evidence-based guidelines.