PACE Medical Director of Resource Management (Part Time - 20 hours/week)

San Ysidro Health•San Diego, CA

116d•$139 - $189

About The Position

The San Diego PACE Medical Director of Resource Management promotes high-value care by overseeing the clinical integrity and medical necessity of outpatient, inpatient, and post-acute care reviews. The role recommends appropriate, cost-conscious services to support optimal outcomes and regulatory compliance. It provides clinical leadership for resource management, utilization review, appeals, denials, and complex case determinations, while working with PACE teams, health plan operations, providers, and executive leadership. The Medical Director conducts or directs timely medical necessity reviews across acute and post-acute settings, applies evidence-based guidelines and CMS criteria, and supports appropriate care transitions and continuity. The role also oversees clinical documentation, coding and risk adjustment, medical policies, practitioner practice patterns, audit readiness, and regulatory compliance. It partners with resource management, care management, interdisciplinary teams, and internal and external providers to promote consistent, high-quality care at reasonable cost. Work is performed in a combination of clinical, office, hospital, skilled nursing facility, and community-based settings as needed. This is a part-time position of 20 hours per week.

Requirements

Graduate from an accredited school of medicine.
Current, active, unrestricted California MD or DO license.
DEA license.
Current BLS certification.
Board certified or board eligible in a primary care specialty.
At least 5 years of experience in Internal Medicine, Geriatrics, and/or Family Medicine.
At least 3 years in a resource management or medical leadership role within managed care, a health plan, or a value-based care setting.
Experience with evidence-based clinical guidelines for utilization review, such as InterQual or Milliman Care Guidelines (MCG).
Advanced proficiency in MS Office and medical software EPIC and QuickCap.
Strong interpersonal and negotiation skills in physician-to-physician interactions and with clinical and non-clinical care management and interdisciplinary team staff.
Excellent written and verbal communication skills.
Strong experience in outpatient, inpatient, and post-acute case review and deep knowledge of Medicare and Medicaid/Medi-Cal regulations and CMS coverage criteria.
Meet pre-employment requirements, including I-9, physical, positive background and reference checks, complete application, new hire orientation, and pre-employment PPDs.
Comply with mandated vaccinations and all boosters as a term and condition of employment.

Nice To Haves

Advanced degree such as MS, MPH, MHA, or MBA.
PACE clinical experience.
ACLS certification.
PACE resource management experience.

Responsibilities

Determine the appropriateness and medical necessity of health care services provided to San Diego PACE members, identify care patterns, and support interventions to reduce unnecessary admissions or extended stays.
Support the San Diego PACE resource management program and action plans to ensure members receive appropriate care in the most effective setting and in a timely manner.
Evaluate utilization management practices and monitor for over- and under-utilization.
Educate and interact with network providers, PACE primary care physicians, and staff about resource utilization management best practices.
Lead knowledge, implementation, training, and supervision concerning medical necessity criteria.
Maintain the integrity of internal and external appeals processes and address applicable Medi-Cal, PACE, and other regulatory requirements.
Conduct retrospective claims and appeals reviews and resolve grievances related to medical necessity determinations.
Attend or chair committees as required, including credentialing and Pharmacy and Therapeutics committees.
Evaluate authorization requests, support nurse resource management specialists, review cases requiring concurrent review, and manage the denial process.
Monitor care and services across hospitals, skilled nursing facilities, and home care to support quality, cost-efficiency, and continuity.
Ensure medical decisions are made by qualified medical personnel, are not influenced by fiscal or administrative considerations, and meet standards for acceptable medical care.
Ensure medical protocols and rules of conduct are followed by San Diego PACE and network medical personnel.
Develop and implement San Diego PACE Health Plan medical policies.
Support and educate primary care physicians and specialty networks, monitor practitioner practice patterns, and recommend corrective action as needed.
Promote clinical practice guidelines and evidence-based medical practices.
Use information technology and data analytics to produce tools for reporting, monitoring, and improving resource and utilization management.
Participate in regulatory, professional, and community activities.
Work closely with site Medical Directors, primary care physicians, the Behavioral Health Director and providers, the Director of Health Plan, and executive leaders, particularly the CMO, Senior Program Director, and CFO.
Provide clinical expertise to Health Plan Operations through strategic partnership and resolution of escalations involving admission status, discharge delays, denial management, and cost-conscious outpatient primary and specialty care.
Guide timely care determinations using CMS regulations and evidence-based practices, including InterQual, in collaboration with PACE care management and interdisciplinary teams, PACE primary care physicians, Behavioral Health providers, and external providers.
Conduct or direct timely medical necessity determinations for outpatient and inpatient care and post-acute services, including SNF, ALF, LTACH, palliative and hospice care, and home health.
Apply San Diego PACE best-practice guidelines, InterQual, and CMS criteria to assess the appropriateness of acute care services.
Lead peer-to-peer discussions with PACE Site Medical Directors, primary care providers, PACE staff, and external network and non-contracted providers to direct appropriate levels of care and support quality care with timely, accurate documentation.
Oversee HCC ICD-10 diagnosis coding, Hierarchical Category Code, and Risk Adjustment Factor scores to support PCP quality, timely clinical care, documentation, and outcomes.
Serve as the primary physician reviewer for escalated or complex resource management cases requiring expert medical judgment.
Partner with resource management, care management, and interdisciplinary teams to support consistent, effective, high-quality care at reasonable cost.
Ensure decisions are documented according to PACE, NCQA, and CMS requirements and support audit preparedness and delegated oversight.