San Gabriel Valley

Regal Medical Group•Covina, CA

18d•$250,000 - $350,000

About The Position

Regal Medical Group, Lakeside Community Healthcare, and Affiliated Doctors of Orange County are seeking an experienced physician leader to support their network in Pomona, Chino, San Gabriel Valley, and surrounding communities. The Medical Director helps ensure patients receive appropriate care at the right time and in the right setting through medical necessity review, care coordination, and strong provider relationships. The role actively participates in pre-service reviews and applies clinical guidelines to determine medical necessity. The Medical Director makes or recommends approval, denial, modification, or redirection decisions, collaborating with physician reviewers, nurses, and Medical Directors to deliver high-quality, cost-effective care consistent with medical management and referral processing guidelines. The position also supports provider relations, quality improvement, grievances, appeals, and peer review.

Requirements

Doctor of Medicine (MD) degree.
At least five years of prior clinical experience.
Strong clinical knowledge and familiarity with clinical research principles.
Ability to interpret and apply clinical guidelines and organizational policies in day-to-day decision-making.
Strong proficiency in MS Office programs, including Word, Excel, Outlook, Access, and PowerPoint, and ability to conduct internet research.
Excellent verbal and written communication skills, including the ability to explain complex clinical and utilization concepts to diverse audiences.
Ability to type at least 50 words per minute accurately.
Strong organizational skills and ability to work effectively in a multitasking, high-stress environment.
Ability to manage multiple projects, reset priorities to meet deadlines, and seek assistance appropriately when priorities conflict.
High personal ethics; self-motivation and drive to improve patient care and operational performance.
Ability to work with all levels of management and develop positive working relationships with medical directors and department heads.
Ability to handle confidential matters responsibly and adhere to regulatory and organizational standards.
Ability to attend on-site department meetings and trainings when needed.

Nice To Haves

Specialty training and/or managed care experience.
Board certification; board-eligible candidates are acceptable.
At least two years of managed-care or health-plan experience.

Responsibilities

Manage and promote medical management principles to facilitate appropriate care at the right time and in the right setting.
Participate in team-based pre-service medical necessity review of patient care with medical directors, nurses, and coordinators.
Review prior authorization requests using appropriate evidence-based clinical guidelines and policies.
Identify high-risk patients and coordinate with the high-risk team to improve outcomes and reduce avoidable utilization.
Meet periodically with primary care physicians, specialists, and provider groups to review patient-care best practices and referral quality.
Perform prior authorization functions for various employer campuses, including cross coverage, secondary and tertiary review, and medical director decision-making as needed.
Conduct retroactive claims reviews for outpatient and inpatient care as needed.
Work with the network management team to establish and maintain provider relationships within the IPA.
Serve as a resource to IPA providers on utilization management and patient-care matters, including authorization criteria and documentation expectations.
Participate in review and response to grievances, appeals, and peer review cases under internal Quality, Grievance & Appeals programs.
Attend and contribute to meetings to review, develop, and improve quality improvement and peer review processes and programs.
Provide verbal counseling to IPA providers following grievance and appeals determinations and collaborate on corrective action plans and follow-up.

Benefits

Employer-paid comprehensive medical, pharmacy, and dental coverage for employees.
Vision insurance.
Flexible Spending Account (FSA).
Employer-paid life insurance.
Employee Assistance Program (EAP).
Behavioral health services.
401(k) Retirement Savings Plan.
Income protection insurance.
Vacation time, sick days, and paid holidays.
Company celebrations and Employee Referral Bonus program.
Tuition reimbursement and License Renewal CEU Cost Reimbursement Program.
CME stipend and paid CME time.
Malpractice insurance coverage.
Business-casual working environment.
Mileage.
Sign-on bonus.
Discretionary awards.