Associate Medical Director - Santa Clarita, United States - MedPOINT Management

Description

Job Description

Job Description
MedPOINT Management (MPM)

Department:
Utilization Management (UM)

Title Associate Medical Director
Summary

The Associate Medical Director is responsible for providing medical interpretation and decisions about appropriateness of services provided by other healthcare professionals in compliance with Utilization Management policies, procedures, and state regulations.

The Associate Medical Director will report to Utilization Management's Medical Director.
Duties and Responsibilities

• Assist the Medical Director in the implementation, supervision, oversight, evaluation and assuring compliance with all UM requirements
• Assist the Medical Director formulate UM policies and procedures, including identification of criteria to be used as a basis for authorization and review decisions, and determine cases to be sent to MD for review
• Assist the Medical Director in maintaining and enforcing appropriate guidelines and hierarchy and promote best practices implementation to ensure they are current
• Apply knowledge of laws and regulations, government (Medicare, Medi-Cal, Commercial, POS, etc.) and insurance benefits to UM decision making
• Review service authorization requests and provide recommendations for utilization review, medical necessity and appropriateness of care
• Actively review utilization patterns and appropriateness in areas such as emergency department charges, specialist consultations, downstream utilization of limited access and high utilization medical resources from both a physician and

supportive/ancillary

services

• Return cases in a timely manner with clear and concise rationale and documented criteria
• Be available as a key contact for the UM nurses when evaluating specified complex cases determining benefit or administrative uses
• Conduct peer-to-peer discussions with ordering physicians, physician assistants, or nurse practitioners as needed to provide education regarding established guidelines for managed services
• Conduct peer-to-peer with Health Plan Medical Directors to discuss grievances, appeals, and/or overturns
• Review quality of care issues and provide corrective action plans, education, and counseling through the UM Committees
• Serve as a resource and liaison to primary care physicians, specialists, hospitalists to encourage optimal utilization patterns, addressing issues, inquiries, and resolutions
• Assume an active role in development and promotion of managed care systems within the IPA
• Implement an educational process on a regularly scheduled basis for Utilization Management
• Assist Inpatient UM Supervisors in review of daily hospital census logs and provide guidance to case managers
• Work with other Medical Directors to provide round the clock coverage for support of medical decisions during off hours, holidays, and weekends
• Meet regularly with the Medical Director and leadership to discuss process improvements
• Attend UM and QM meetings and serve as a resource for decision-making

Minimum Job Requirements

• M.D. or D.O. degree with current unrestricted medical license in the state of California
• 1+ year experience as an Associate Medical Director
• 5+ years clinical experience in internal medicine or hospitalist
• Access to current criteria and specialists available to group
• Knowledge of current and new regulations on federal, state and local levels as well as practice guidelines and standards of practice

Skill and Abilities

• Strong interpersonal skills
• Effective communication, both verbal and written
• Ability to work effectively with all levels of the organization and stakeholders, including Health Plans and physicians

MedPOINT, a large MSO in the San Fernando Valley, offers competitive salaries and benefits in a collaborative working environment. For immediate consideration of this position, please e-mail your resume and salary requirements to

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