Medical Director, Medical Management

L.A. Care Health Plan•Los Angeles, CA

2d•$206,311 - $350,729

About The Position

The Medical Director, Medical Management, performs and oversees quality assurance for the daily clinical operational functions and traditional medical management services of L.A. Care Health Plan. These functions include prior authorization and retrospective review, concurrent review for hospitals, skilled nursing facilities and long-term care, daily hospital rounds and discharge planning, transitions of care, complex care and interdisciplinary care team rounds, appeals and grievances, and provider disputes. The role works closely with Health Services departmental leaders and other stakeholders to ensure clinical operations are timely, compliant with regulations, and consistent with evidence-based care standards. The Medical Director monitors program effectiveness and operational processes, supports optimization and administrative efficiency, and ensures daily work is tracked, audited, and reviewed to support staff education and improvement. The position provides medical leadership and clinical input to improve and develop member and provider services, support regulatory compliance, reduce administrative costs and burden, and advance organizational goals. It collaborates with internal and external stakeholders, including providers, medical groups, hospitals, mental health and substance use providers, social services providers, and regulatory organizations.

Requirements

Doctor of Medicine (M.D.) or Doctor of Osteopathic Medicine (D.O.).
Minimum of 8 years of clinical practice experience post-residency.
Active, current, and unrestricted California physician license.
Active, current, and unrestricted board certification, preferably in a primary or medical specialty.
Ability to provide leadership to physicians, nurses, and other health care professionals, and interest and involvement in the affairs of the health care community.
Demonstrated ability to work as part of a team and solve problems collaboratively.
Excellent written and verbal communication, negotiating, consensus-building, teamwork, planning, and implementation skills.
Knowledge of Medicare and Medicare-Medicaid.
Familiarity with federal programs such as Medi-Cal, Medicare, and Covered California.
No history of disciplinary action by a State Medical Board.

Nice To Haves

Prior experience in medical management or physician advisory roles.
Experience with Medicaid managed care and/or other governmental programs serving underserved and safety-net populations, including women, children, persons with disabilities, seniors, and people from ethnic and cultural backgrounds.
Experience with National Committee for Quality Assurance (NCQA) accreditation and Department of Health Care Services (DHCS) and Department of Managed Health Care (DMHC) audits.
Experience with health information technology, data analytics, and process improvement.

Responsibilities

Ensure accreditation, regulatory, clinical operational, documentation, and reporting standards are met.
Perform clinical review of prospective, concurrent, and retrospective reviews.
Participate in creating authorization rules.
Review and participate in monitoring staff performance.
Monitor processes and ensure team objectives are met.
Support a culture and environment that reinforces administrative efficiency and continuous improvement.
Serve as a clinical resource to clinical and non-clinical staff and contracted delegates.
Participate in on-call coverage.
Perform daily care management functions, including care team rounds.
Review appeals, grievances, and provider disputes.
Provide strategic and operational leadership in creating and implementing a regional utilization management model.
Provide clinical and policy expertise for relevant programs, projects, vendors, new technology, and benefit reviews.
Build productive, collaborative relationships with external stakeholders, including medical groups, hospitals, hospitalists, community-based providers, and social service providers.
Manage team-specific or departmental projects as assigned by leadership.
Provide input on relevant clinical service areas for public and community-based communications, root cause analysis, and corrective actions.
Support and interpret relevant data and metrics.
Assist with developing, reviewing, and implementing policies and procedures to ensure departmental work meets regulatory and accrediting standards for all products.
Chair or facilitate committees or meetings as assigned by leadership.
Perform other duties as assigned.