Utilization Management, Medical Director-Fully Remote (CA License required)
Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.
• *** MUST HAVE CALIFORNIA LICENSE***
• ** Utilization Management Experience***
The Utilization Management, Medical Director works with Senior Medical Officers, Regional Medical Officers, Extensivists, the Healthcare Services Team (Case managers, Social Workers, Utilization Managers) to develop and implement methods to optimize use of Institutional and Outpatient services for all patients while also ensuring the quality of care provided. Through remote access to our web-based Portal, physician advisors will complete clinical reviews for medical necessity, treatment appropriateness and compliance.
Job Responsibilities: Processes second level reviews in compliance with Medicare/CMS: NCD, LCD and Milliman guidelines for Inpatient, Outpatient, Skilled Facilities Level of Care and Pharmacy.
2. Provides appropriate level of care classifications as well as continued stay reviews in compliance with CMS and Milliman guidelines.
3. Acts as a liaison between the medical staff, utilization review and 3rd party payers to effectively promote the appropriate levels of medical care.
4. Reviews the entire claim denial process, including Appeals and Grievances.
5. Serves as a Physician member of the utilization review team.
6. Works with Interdisciplinary Team to develop case management protocols and provide oversight for NP’s/PA’s training.
7. Acts as a Clinical Leader for HEDIS and STARS projects and serves as Clinical Advisor for HCC and RAF.
8. Serves as a Chairperson for Medical Quality Committee and provide Clinical Oversight for Chronic Disease Management programs and Quality Outcome.
9. Collaborates closely and provide assistance to Quality Director.
10. Works with Extensivists and Middle Level Practitioners (NP’s/PA’s) to reduce length of institutional stay, all cause readmission reduction and ER overutilization ensuring patients and therapeutic modalities.
11. Assists the organization to challenge physician practices in order to achieve the organization's clinical outcomes and quality goals.
Supervisory Responsibilities:
Oversees assigned staff. Responsibilities include recruiting, selecting, orienting, and training employees; assigning workload; planning, monitoring, and appraising job results; and coaching, counseling, and disciplining employees.
Qualifications: • Required: Minimum of 3 years of experience in hospital-wide or skilled nursing facility position involving clinical care, quality management, utilization and case management, or medical staff governance required.
• Preferred: Experience as a Physician Advisor a plus
Education:
• Required: Completion of medical school and specialty residency (preferably in internal medicine) required. Subspecialty or other post-residency fellowship and board certification preferred.
Specialized Skills:
• Required:
California License
UM Experience
Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others.
Ability to build rapport with medical staff and management leadership to obtain necessary approvals of new strategies for utilization management.
Knowledge of current medical literature, research methodology, healthcare delivery systems, healthcare financial/reimbursement issues, and medical staff organizations.
Dedication to the delivery of high-quality, cost-effective, efficient patient care services
Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors;
Mathematical Skills: Ability to perform mathematical calculations and calculate simple statistics correctly
Reasoning Skills: Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution.
Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.
Licensure:
Required: Applicants must have current, non-restricted licensure as required for clinical practice in the state of California.
Work Environment:
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Essential Physical Functions:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
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• *** MUST HAVE CALIFORNIA LICENSE***
• ** Utilization Management Experience***
The Utilization Management, Medical Director works with Senior Medical Officers, Regional Medical Officers, Extensivists, the Healthcare Services Team (Case managers, Social Workers, Utilization Managers) to develop and implement methods to optimize use of Institutional and Outpatient services for all patients while also ensuring the quality of care provided. Through remote access to our web-based Portal, physician advisors will complete clinical reviews for medical necessity, treatment appropriateness and compliance.
Job Responsibilities: Processes second level reviews in compliance with Medicare/CMS: NCD, LCD and Milliman guidelines for Inpatient, Outpatient, Skilled Facilities Level of Care and Pharmacy.
2. Provides appropriate level of care classifications as well as continued stay reviews in compliance with CMS and Milliman guidelines.
3. Acts as a liaison between the medical staff, utilization review and 3rd party payers to effectively promote the appropriate levels of medical care.
4. Reviews the entire claim denial process, including Appeals and Grievances.
5. Serves as a Physician member of the utilization review team.
6. Works with Interdisciplinary Team to develop case management protocols and provide oversight for NP’s/PA’s training.
7. Acts as a Clinical Leader for HEDIS and STARS projects and serves as Clinical Advisor for HCC and RAF.
8. Serves as a Chairperson for Medical Quality Committee and provide Clinical Oversight for Chronic Disease Management programs and Quality Outcome.
9. Collaborates closely and provide assistance to Quality Director.
10. Works with Extensivists and Middle Level Practitioners (NP’s/PA’s) to reduce length of institutional stay, all cause readmission reduction and ER overutilization ensuring patients and therapeutic modalities.
11. Assists the organization to challenge physician practices in order to achieve the organization's clinical outcomes and quality goals.
Supervisory Responsibilities:
Oversees assigned staff. Responsibilities include recruiting, selecting, orienting, and training employees; assigning workload; planning, monitoring, and appraising job results; and coaching, counseling, and disciplining employees.
Qualifications: • Required: Minimum of 3 years of experience in hospital-wide or skilled nursing facility position involving clinical care, quality management, utilization and case management, or medical staff governance required.
• Preferred: Experience as a Physician Advisor a plus
Education:
• Required: Completion of medical school and specialty residency (preferably in internal medicine) required. Subspecialty or other post-residency fellowship and board certification preferred.
Specialized Skills:
• Required:
California License
UM Experience
Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others.
Ability to build rapport with medical staff and management leadership to obtain necessary approvals of new strategies for utilization management.
Knowledge of current medical literature, research methodology, healthcare delivery systems, healthcare financial/reimbursement issues, and medical staff organizations.
Dedication to the delivery of high-quality, cost-effective, efficient patient care services
Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors;
Mathematical Skills: Ability to perform mathematical calculations and calculate simple statistics correctly
Reasoning Skills: Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution.
Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.
Licensure:
Required: Applicants must have current, non-restricted licensure as required for clinical practice in the state of California.
Work Environment:
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Essential Physical Functions:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Apply tot his job
Apply To this Job