Medical Director (Part-Time)

Personify Health•, CA

1d•$91 - $114•Remote

About The Position

Personify Health created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. We serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes. Together, our team is on a mission to empower people to lead healthier lives. Learn even more about the work that drives us at personifyhealth.com.

Requirements

Basic computer literacy
The ability to work on multiple screens, and proficient typing skills.
Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, and Outlook
Excellent verbal and written communication skills
Ability to speak clearly and convey complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others.
Ability to work independently and utilize written resources to problem solve.
Knowledge of medical claims and ICD-10, CPT, HCPCS coding
Strategic thinking with proven ability to communicate a vision and drive results
Proficient in analysis and interpretation of clinical data
Comfortable with multiple accountabilities and matrix management
Proven record of strong relationships and working with diverse teams
Demonstrated ability to work independently with excellent judgment
Ability to work from home or in a virtual environment
Strong interpersonal skills necessary to effectively communicate with medical personnel and members
Analytical and problem-solving skills necessary to identify and review pertinent information
The ability to incorporate analytical data into new or existing clinical programs to enhance quality of care
Ability to present data analysis in written format to upper management in a clear, concise manner
Ability to maintain an extremely elevated level of confidentiality
Able to successfully handle competing priorities
Experience in the Utilization Review Process which includes Prior-Authorization/Pre-Certification, Retro Reviews, Concurrent Reviews and Post Service Claims Review
Experience in the grievance, appeals process, and ability to work on escalated issues as they arise
Ability to provide quality oversight to personnel, process improvement, policies, and procedures
Familiarity with National Guidelines such as MCG or InterQual, medical policy or commonly used guidelines from Specialty Colleges
Experience in disease management with knowledge and understanding of disease progression.
Knowledgeable of the Federal, State and ERISA regulation
MD or DO degree and 5+ years of direct clinical patient care experience post residency or fellowship, which preferably includes some experience in an inpatient environment.
Current and ongoing Board Certification in an approved ABMS Medical Specialty.
A current and unrestricted license in the state of California and willing to obtain additional license(s), if needed. (Optional)
No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements.
Minimum 5 years of Utilization Review or Hospital experience required.
Ability to perform the essential job functions safely and successfully with or without reasonable accommodation, including meeting qualitative and/or quantitative productivity standards.
Ability to maintain regular, punctual attendance.
Ability to sit for 6-8 hours.
Constant use of computer keyboard and mouse; repetitive use of both hands.
Occasional to frequent twisting of neck; occasional bending of neck and at waist.

Nice To Haves

Some experience in an inpatient environment.
Minimum 3 years of compliance related experience preferred.
Managed Care experience preferred in utilization review and case management.

Responsibilities

Review claims for medical necessity for prior authorization, continued stay review and post service.
Read, interpret, and apply medical policy, guidelines, and research to utilization review.
Issue adverse determinations while performing medical necessity evaluation.
Discuss with external physicians by phone to gather additional clinical information or discuss determinations regularly, and in some instances, these may require conflict resolution skills.
Keep the team informed of clinical updates through educational opportunities by developing educational materials for staff.
Work with the VP of Care management to establish work procedures and processes that support company and departmental standards, procedures, and strategic directives.
Oversee the negotiation and implementation of cost management strategies to affect quality outcomes and reflect this data in monthly case management reviews as it relates to clinical aspects in case management and utilization review rounds.
Exercise independence in meeting departmental expectations and meet compliance timelines.
Meet productivity, quality, and turnaround times daily.
Pass external audits to include URAC and NCQA.
Maintain HIPPA compliance per company’s policy and procedures.
Maintain confidentiality and minimum requirement rules.
Complete all required yearly training per company’s expected period.