Medical Director

Altais•Remote - CA, CA

49d•$222,750 - $267,300

About The Position

The Medical Director of Utilization and Medical Management will report directly to the Senior Medical Director with a dotted line to the Chief Officer for Health and Innovation, and work closely with the Altais Clinical Leadership team in ensuring the delivery of high-quality, efficient and comprehensive healthcare services throughout the continuum of care. This role facilitates and provides information and education for Altais to enable better understanding and skill enhancement in the medical, financial, and utilization practice functions of managed care. The Medical Director plays a vital role in both the development and implementation of Utilization Management policy and procedures. This physician is chosen based upon their knowledge of medical practice, experience in Managed Care, Utilization, Quality Management programs and an ability to interact well with the other physicians. The Medical Director will provide cooperative leadership and direction to the UMC (Utilization Management Committee) Primary Care Physicians (PCP) and all Specialist Physicians as assigned by the Senior Medical Director. The Medical Director may be asked to co-chair several committees including the Utilization Management Committee, The Quality Management Committee, the Peer Review and Patient Safety Committee, and others as needed. The Medical Director may be responsible for interfacing with health plans regarding benefits, coverage issues, response to appeals, attend HMO hearing on appeals and administrative issues which cannot be settled by the Case Managers and/or Management. The Medical Director will work closely with physician leaders across all healthcare settings to ensure that patient care is managed in a cost containment manner without compromising health outcomes. This physician leader will facilitate clinical rounds with the Case Managers & Management to ensure bed day performance goals are met. Collaborate with the Senior Medical Director and Chief Office for Health and Innovation to engage network physicians with regard to performance, cost, clinical appropriateness and authorizations. This individual takes an active role in the development and promotion of managed care systems within One Altais. This will include development of UM policies and procedures, identifying the type of criteria to be used for authorization review, and implementation of a regular forum in which to educate PCPs and specialists on utilization management systems. The Medical Director also serves as an important resource and key contact for identified case management problems and participates in IDCT (Interdisciplinary Care Team) Meetings. The Medical Director supports the Senior Medical Director as a resource person for Physician Education on UM and input into the One Altais UM goals and objectives. Coordination of prospective, concurrent, retrospective review including denial and/or approval of all outside medical services referrals as necessary. Develop and maintain written medical care protocols and assure UM Standardization. Chart Reviews for Appropriateness of applying clinical guidelines. Physician to Physician liaison for UM related issues. Prepare and review Decision Validation Criteria as required by UM. Required Meetings: UM Committee Health Plan Joint Operations Meetings Hospital Joint Operations Meeting One Altais Meetings involving Utilization Management

Requirements

Doctor of Medicine degree
Valid California licensure
Current Board certification, preferably in a broad based specialty such as Internal Medicine, Family Practice, Emergency Medicine, Geriatrics, General Surgery or Pediatrics.
A minimum of twelve (12) years as a practicing inpatient and outpatient physician in a managed care environment.
Active and in good standing unrestricted MD licensure in the state of California

Responsibilities

Plays a vital role in both the development and implementation of Utilization Management policy and procedures.
Works to continually enhance the overall efficiency and quality of care for patients served by One Altais through effective network management.
Develop and maintain collaborative functioning relationships with key providers, particularly thought leaders, across the One Altais service delivery footprint.
Provide cooperative leadership and direction to the UMC (Utilization Management Committee) Primary Care Physicians (PCP) and all Specialist Physicians as assigned by the Senior Medical Director.
May be asked to co-chair several committees including the Utilization Management Committee, The Quality Management Committee, the Peer Review and Patient Safety Committee, and others as needed.
May be responsible for interfacing with health plans regarding benefits, coverage issues, response to appeals, attend HMO hearing on appeals and administrative issues which cannot be settled by the Case Managers and/or Management.
Work closely with physician leaders across all healthcare settings to ensure that patient care is managed in a cost containment manner without compromising health outcomes.
Facilitate clinical rounds with the Case Managers & Management to ensure bed day performance goals are met.
Collaborate with the Senior Medical Director and Chief Office for Health and Innovation to engage network physicians with regard to performance, cost, clinical appropriateness and authorizations.
Takes an active role in the development and promotion of managed care systems within One Altais. This will include development of UM policies and procedures, identifying the type of criteria to be used for authorization review, and implementation of a regular forum in which to educate PCPs and specialists on utilization management systems.
Serves as an important resource and key contact for identified case management problems and participates in IDCT (Interdisciplinary Care Team) Meetings.
Supports the Senior Medical Director as a resource person for Physician Education on UM and input into the One Altais UM goals and objectives.
Coordination of prospective, concurrent, retrospective review including denial and/or approval of all outside medical services referrals as necessary.
Develop and maintain written medical care protocols and assure UM Standardization.
Chart Reviews for Appropriateness of applying clinical guidelines.
Physician to Physician liaison for UM related issues.
Prepare and review Decision Validation Criteria as required by UM.