Medical Director - TPA

Location: San Jose, CA
Date Posted: 03-30-2018
Medical Director (MD or DO) for Medical Management - Managed Care
San Jose, CA

Job Summary:
The Medical Director for Medical Management will be responsible for ensuring the effective utilization of medical services through the application of nationally recognized medical necessity criteria. The Medical Director is responsible for providing clinical expertise and business direction in support of medical management programs to promote the delivery of high quality, constituent responsive medical care. They are a critical medical and business leader and contact for external providers, plan sponsors, and regulatory agencies and participate in strategic medical management.  The Medical Director for Medical Management provides utilization review of requests for various services, to include review of all levels of denials and appeals, and assisting case management operations.  They provide medical leadership to ensure excellent quality of care and service is provided to our members and clients that are efficient and cost effective.  This positions leads and directs medical management programs, but does not involve direct supervision of individual staff members.

Position Description:
Makes Medical Necessity determinations, conducts utilization review and overall quality evaluation of requested medical and surgical services and hospital stays including concurrent and prospective inpatient and outpatient services.  Partners with other leaders in medical management to increase effectiveness of medical management programs and promotes integration of other internal medical programs.  Assists in the development, implementation, and monitoring of Disease Management, Quality Management, and Utilization Management projects, including preparing study reports for internal and external use.
Provides technical expertise in medical management by direct decision-making in the areas of pre-authorization, pre-admission, admission, continued stay, discharge, and re-admission reviews and quality reviews against standard supplied review criteria and coverage guidelines for inpatient, outpatient, emergency room, surgical, and specialized procedures.  Participates in the development of policies and procedures for authorizing and monitoring out of area care provided.  Leverages the use of predictive modeling and medical cost forecasting capabilities to improve decision making relative to cost spending.  Analyzes medical cost drivers and develops specific plans to reduce excessive cost.   Uses available data and chart reviews; all documentation and material for review is sent directly to the physician reviewer.  Takes part in periodic consultations and conversations with peers and practitioners in the field.  Consults with referring physicians as deemed necessary by reviewer or when reconsideration is requested; consults with other staff or vendors as required. 
Oversees or directly preforms all Utilization Management decisions including specific Denials and Appeals.  Educates physicians about utilization practices to promote high quality, cost effective care.   Assists with the coordination of the appeal process for denied services, including making appeal determinations.  Coordinates with a staff of qualified clinicians accountable to the organization for decisions affecting consumers, and that any appeals are reviewed by non-subordinate board certified specialists.  Provides professional insight for all federal and state quality improvement projects and accreditation activities (URAC / NCQA).  Works collaboratively with other functional areas that interface with medical management including provider relations.
Background Profile:

Formal education including a Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree.
Must hold and maintain an active unrestricted state license to practice medicine.
At least 5 years directly applicable clinical practice experience, and board certification, in the US.
Around 2-3 years’ experience working for a Managed Care Organization (Health Plan/IPA/HMO/TPA, etc); preferably working with government sponsored programs and recipients.
Strong working knowledge of managed care utilization management approaches and principles.
Demonstrated ability to communicate and educate providers regarding principles of utilization management and quality improvement.
Excellent written and verbal communication skills; and strong critical thinking, deductive reasoning and decision making skills are needed.
Ability to implement complex programs and to monitor implementation and modifications. 
The Reward:
Leadership opportunity for an experienced management executive to join a team of leaders committed to service excellence.  Join an organization that is driven to ensure that every person and group they serve receives the greatest possible value for their health care investment.  A great company that fosters team involvement, encourages continuing education, and rewards success.

480.646.3275 (CALL – TEXT – FAX)
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