- Responsible for UM functions for service authorization in accordance with regulatory standards set by ICE/Health Plan and other regulatory agencies.
- Performs daily concurrent review, retro reviews, ER reviews, discharge planning, pre-certification/prior authorization request review and ensures patients meet appropriate level of care based on acceptable evidenced based practices.
- Works collaboratively with Hospitalists, hospital partners, and care teams to provide whole person care that is focused on high quality in a cost effective manner.
- Utilizes authorization matrix, ancillary rosters, DOFR, and/or delegation agreements to drive decision-making.
- Maintains up to date knowledge of rules and regulations governing utilization management processes.
- Performs Peer to Peer meetings.
- Identify gaps in the IPA network and assist in identifying and recruiting new providers. Evaluates, maintains, and updates the preferred Regional network list of specialist, ancillary services, hospitals in collaboration with managed care.
- Monitor utilization trends and communicate program outcomes to IPA leadership and physicians.
- Will provide quality reviews that address the individual needs of the member, align with medical evidence guidelines, and meet compliance requirements.
- Identifies and appropriately documents areas of inappropriate utilization of resources.
- Act as the main point of contact for physicians who wish to speak directly about authorization requests and follow up.
- 3+ years of Health Plan or IPA experience doing UM Authorization Reviews
- 3+ years of experience with UM case review leading to a decision using Medi-Cal and Medicare guidelines
- 3+ years of experience using InterQual or MCG
- Must function within the virtual environment and be able to work individually, while working collaboratively with the medical management team.
- Develops a positive working relationship with internal and external customers
- Maintains positive relationship with a variety of stakeholders, including working closely with primary care physicians, specialists, hospitalist physicians, nursing, and staff, participate in interdisciplinary team meetings.
- Physician (MD or DO) with an active unencumbered license to practice medicine in California and Board Certification in Internal Medicine/ Family Medicine or Pediatrics. Meets all credentialing requirements per IHPC and IIC Credentialing policy. Additional licensure in Texas, Arizona or Nevada preferable
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Medical Director, Medical Management Imperial Management Administrators Services Imperial Manag - Pasadena, United States - Imperial Health Holdings Medical Group
Description
People are the most important asset of Imperial,for this reason the difference and plurality of people, equality of opportunities, non-discrimination and inclusion in the workplace are priority and strategic factors in the Organization.
Imperial maintains a strong will to promote Diversity, Equity, and Inclusion, through inclusive leadership as a lever change and business sustainability.
Imperial Health Plan of California, Inc.is approved by California Department of Managed Health Care to offer full-service Medicare Advantage coverage, including a Medicare Advantage Prescription Drug plan, and a Chronic Condition Special needs plan over numerous counties in California.
Through its affiliates, Imperial Insurance Companies and Imperial Health Plan of the Southwest, Imperial also offers covered services to eligible individuals under the Affordable Care Act-Obamacare in numerous counties in Texas, Utah, Nevada and Arizona.
Our Mission:
To deliver valuable care so that members are healthy in body, mind, and spirit to achieve their inherent potential.
Our Vision:
To deliver value based care that is clinically effective, sustainable, and achieves exceptional outcome.
REQUIRED LICENSURE:
Active unencumbered MD license in California. Additional licensure in Texas, Arizona or Nevada preferable
JOB SUMMARY:
Responsible for Medical Management functions within the areas of inpatient and/or outpatient Utilization Management, Case Management, and Claim adjudication.
Will apply medical judgement and pertinent evidence based clinical guidelines to determine medical necessity on pre-service, concurrent, and retroactive and claims reviews of medical services.
Will adhere to regulation set by state, federal, and other regulatory managed care agencies and as the health plan's contracts stipulate.
Additionally, this position must work collaboratively with the Medical Services and Managed Service Organization (MSO) to process authorizations needing physician review within the required time frame.
As part of a team, is expected to support colleagues and the team to meet medical management performance targets, the coordination of care with social work and mental health counseling, psycho-social support services, in-home support, legal services, skilled nursing, home health, etc.
Responsibilities will include providing advisory input to risk management and quality teams to address initiatives in HEDIS and HCC coding.
Work closely with CMO to improve STAR ratings and HEDIS measures. Assist with review of post-service claims for medical necessity.ESSENTIAL JOB FUNCTIONS:
EXPERIENCE:
ABILITY:
TRAINING:
