Medical Director Outpatient

Position Summary: 

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.
• 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.

The pay range for this position at commencement of employment is expected to be between $200,000 to $300,000 annually; however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, licensure, skills, and experience.

The total compensation package for this position may also include other elements, including a sign-on bonus and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offered.

Details of participation in these benefit plans will be provided if an employee receives an offer of employment.

If hired, employee will be in an “at-will position” and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.

As one of the fastest growing Independent Physician Associations in Southern California, Regal Medical Group, Lakeside Community Healthcare & Affiliated Doctors of Orange County, offers a fast-paced, exciting, welcoming and supportive work environment. Opportunities abound, and enterprising, capable, focused people prosper with us. We promote teamwork, nurture learning, and encourage advancement for all of our employees. We want to see you excel, because we believe that your success is our success.

Full Time Position Benefits:

The success of any company depends on its employees. For us, employee satisfaction is crucial not only to the well-being of our organization, but also to the health and wellness of our members. As such, we are firmly dedicated to providing our employees the options and resources necessary for building security and maintaining a healthy balance between work and life.

Our dedication to our staff is evident in our comprehensive benefits package. We offer a very generous mixture of benefits, including many employer-paid options.

Health and Wellness:

• Employer-paid comprehensive medical, pharmacy, and dental for employees
• Vision insurance
• Zero co-payments for employed physician office visits
• Flexible Spending Account (FSA)
• Employer-Paid Life Insurance
• Employee Assistance Program (EAP)
• Behavioral Health Services

Savings and Retirement:

• 401k Retirement Savings Plan
• Income Protection Insurance

Other Benefits:

• Vacation Time
• Company celebrations
• Employee Assistance Program
• Employee Referral Bonus
• Tuition Reimbursement
• License Renewal CEU Cost Reimbursement Program
• Business-casual working environment
• Sick days
• Paid holidays
• Mileage

Employer will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of the LA City Fair Chance Initiative for Hiring Ordinance.