Medical Director Utilization Management / Job Req 772071248

PRINCIPAL RESPONSIBILITIES:

The Medical Director- Utilization Management (UM), is a member of the Healthcare Services Department of the Alameda Alliance for Health ("health plan"), and assists the Chief Medical Officer (CMO) in developing and implementing clinical policy designed to meet the DHCS triple aim: improving the patient experience of care; improving the health of populations; and reducing the per capita cost of health care. Medical Directors serve as the liaison to the provider network on behalf of the Alliance. In addition to the CMO, the UM Medical Director works closely with the Director of Utilization Management and other leaders to ensure all goals of the UM program are met.

Principal responsibilities include:

• Ensure that medical decisions are rendered unhindered by fiscal or administrative management.
• Lead efforts to meet UM, Case & Disease Management regulatory requirements and accreditation standards.
• Ensure that medical care meets standards for acceptable medical care and establish comprehensive, understandable standards of clinical care that identify desirable, observable characteristics of care, based on state-of-the art, community, state, and national practice guidelines.
• Perform Prior Authorization medical necessity reviews, resolve medically related and potential quality related issues, and issue authorizations, modifications, and denials.
• Perform other duties as requested, such as grievances and appeals.
• Perform peer-peer consultations, maintain effective and consistent communications and professional relationships with providers and delegates.
• Assist in developing and revising policies to support UM activities, including criteria and guidelines for appropriate use of services, clinical practice guidelines and treatment guidelines.
• Comply with the organization's Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.
• Coordinate with other Medical Directors to provide support and appropriate direction on UM issues. (e.g. prior authorizations, PQI, clinical case reviews and dispositions, clinical grievances etc.).
• Monitor vendor and physician compliance with contractual responsibilities in conjunction with the Provider Services department, particularly in the areas of UM.
• Prepare and participate in all regulatory audits of the Plan.
• Participate in the Quality Improvement Health Equity Committee, UM Committee, Peer Review & Credentialing Committee as well as workgroups and ad-hoc physician and provider committees, as needed.
• Develop and participate in clinical rounds with hospital and facility partners.
• Develop and participate in Delegation Oversight.
• Complete other tasks/projects as assigned by the Chief Medical Officer.

PHYSICAL REQUIREMENTS

• Constant and close visual work at desk or computer.
• Constant sitting and working at desk.
• Frequent data entry using a keyboard and/or mouse.
• Frequent use of telephone head set.
• Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
• Frequent lifting of folders and various objects weighing between 0 and 30 lbs.
• Frequent walking and standing.

Number of Employees Supervised: 0

MINIMUM QUALIFICATIONS:

EDUCATION OR TRAINING EQUIVALENT TO:

• Current Doctor of Medicine, active, unrestricted licensed in the State of California, Board certified. Internal or Family Medicine preferred.

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:

• Two years' experience in a managed care environment (preferred), physician group management or integrated health care system management.
• Five years' experience in the practice of medicine.
• Previous experience with a Medicare or D-SNP program.

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):

• Experience and current knowledge in clinical program administration, including utilization management and/or quality management.
• Ability to think strategically and bring vision to the position.
• Ability to integrate clinical and financial data for improved management of clinical programs.
• Ability to develop and maintain successful working relationships with external constituents, physicians, hospitals, ancillary providers, regulators, government officials and the media.
• Knowledge of California public health care programs.
• Experience serving culturally diverse populations.
• Successful track record as a team player, collaborative style and exceptional interpersonal skills.
• Excellent oral and written communication skills.
• Experience in use of various computer system software as well as Windows and current Microsoft Office suite.

SALARY RANGE: $279,364.80 - $419,057.60 ANNUALLY

The Alliance is an equal opportunity employer and makes employment decisions on the basis of qualifications and merit. We strive to have the best qualified person in every job. Our policy prohibits unlawful discrimination based on race, color, creed, gender, religion, veteran status, marital status, registered domestic partner status, age, national origin or ancestry, physical or mental disability, medical condition, genetic characteristic, sexual orientation, gender identity or expression, or any other consideration made unlawful by federal, state, or local laws. M/F/Vets/Disabled.