Regional Medical Director
Are you ready to take your career to the next level and do your life s best work? We at NAMM, a part of OptumCare, deliver a clearly differentiated level of outcome and service adherence. Come join our team and add to our bench strength as we execute on managed care 2.0 bringing together revenue optimization, appropriate utilization, unit cost management and strategic acquisitions. Quality care saves money without exception. North American Medical Management, California, Inc. (NAMM) develops and manages clinician networks, offering a full range of services to assist physicians and other clinicians in their managed care and business operations. For over 17 years, NAMM has been an innovator in health care with a track record for quality, financial stability, extraordinary services and superior electronic capabilities. We are currently recruiting for a talented and experienced Regional Medical Director who enjoys taking challenges, thrives on excellence and shares our vision and values and commitment to quality care and ability to contribute in a highly collaborative team environment. Overview: This key leadership opportunity interacts with Physicians and IPA staff to ensure that patient needs are met in an efficient and medically appropriate manner. Responsible for the Medical Management functions that include vendor relations, Utilization Management and business development. In addition, this role provides prime management, oversight and development for major program and functional areas within Medical Management including medical policy, patient centered medical home, Medicaid, Health and Wellness, population management, and reporting capabilities. Collaborate with Physicians and other providers, especially PCMH practices, to improve the quality and efficiency of care in the network and integrate these providers into clinical initiatives. Primary Responsibilities:
- Works primarily with the physician community around issues of patients, balancing business and clinical concerns.
- Provides limited utilization management for outpatient medical, surgical and pharmacy activity. Participates in medical appeals activity.
- Reviews all 2nd-level overturned cases related to medical necessity / investigational issues in the context of potential medical policy updates.
- Works with the Appeals area on appeals related to utilization management issues.
- Provides medical leadership and physician advice to the quality management area with respect to quality improvement studies, quality improvement committees, primary care assessments (both office-site assessments and medical record document reviews).
- Performs peer reviews on quality complaints, sentinel events, and quality-of-care referrals.
- Serves as Physician Advisor for other areas within the company, including but not limited to Sales and Marketing, Underwriting, PHP, and Provider Services.
- Provides medical leadership and advice for conformance with standards and guidelines for NCQA, URAC, state and federal regulators, and other accrediting bodies. Acts as liaison for communication with physicians, hospitals, and other providers in the community. Reviews customer service and claims inquiries.
- Possess a current and unrestricted MD or DO license in California
- Board certification in chosen specialty
- Minimum three years of experience working as a Medical Director in a managed care setting with minimum three years of experience in utilization management, utilization review and prior authorization.
- Minimum three years of experience interacting with both group and IPA Physicians including experience with inpatient / hospitalist management.
- Experience supervising Advanced Practice Clinicians
- Prior experience working with clinical information technology systems
- Excellent presentation skills; comfortable presenting 1:1 and in group setting
- Excellent communication skills
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