Medical Director, Utilization Management

HealthCare Partners is looking for talented Medical Director, Utilization Management. Opportunity for experienced leader to combine clinical care and utilization management expertise while leading dedicated Utilization Management team. To impact, develop and improve Utilization Management criteria, protocols and UM trends; and work in collaboration with Regional Medical Director and medical management team.

Position Details: 

• Responsible for oversight of Utilization Management

• Review of requests for service; performing post service / claims review and make determination based on medical necessity and appropriateness of care for cases within established guidelines.
• Adhere to regulatory, health plan, and clinical guidelines for denials.
• Monitor utilization trends and work with Regional leadership team when interventions are indicated.
• Work collaboratively with UM Physician Reviewers, Utilization Management and Care Management teams.

• Provide feedback and coach UM Physician Reviewers with UM initiatives.
• Conduct and participate in Utilization Management meetings for region.

Requirements:

• Unrestricted CA Medical License
• Current CA DEA certificate required prior to start date
• Current Board Certification
• Minimum five years clinical experience with 2+ years medical management background including experience in medical group, health plan setting; claims review (including all specialties) and utilization.
• Strong knowledge of CMS regulations, regulatory requirements and health plans; HMO, commercial and Medi-Cal.
• Ability to work effectively across all functions, departments, and levels within the region and organization.
• Successful track record as interactive leader, collaborative style with excellent oral and written communication skills
• Strong analytical and decision making skills; excellent oral and written communication
• Computer proficient

Position is based in Orange County corporate office with nearby freeway access. We foster a culture of innovation, collaboration and to work with dedicated team of healthcare professionals committed to making a difference in the lives of our patients each and every day. Healthcare Partners offers competitive pay with financial incentives for yielding strong metrics on quality care while seeing a lower than average census.  We provide our clinicians an excellent benefit package which includes leadership pathways, CME reimbursement, paid license renewals and many other benefits, charitable sponsorships, and volunteer opportunities. If you’re looking to join a physician-led community that is making a difference in healthcare, Healthcare Partners is the place for you.

About Us

Healthcare Partners manages and operates medical groups and affiliated physician networks in California, Nevada, New Mexico, Florida, Colorado and Washington in its pursuit to deliver excellent-quality health care in a dignified and compassionate manner. As of June 30, 2016 Healthcare Partners provided integrated care management for approximately 760,000 patients. Healthcare Partner’s leadership development initiatives and social responsibility efforts have been recognized by Fortune, Modern Healthcare, Newsweek and WorldBlu.  

We are committed to bringing the benefits of coordinated care to our patients and to taking a leading role in the transformation of the national healthcare delivery system to assure quality, access, and affordable care for all. If you're looking to make a difference with a large, financially stable, well-recognized medical group, Healthcare Partners may be the employer for you.