Regional Medical Director

Partnership HealthPlan of California•Redding, CA

8d•$259,564 - $363,389

About The Position

To oversee the appropriateness and quality of care delivered through Partnership HealthPlan of California and for the cost-effective utilization of services.

Requirements

Medical Doctor or Doctor of Osteopathy, plus completion of a residency program.
Minimum of 5 years post-residency clinical experience.
Current valid California Medical License.
Board Certification in an American Board of Medical Specialist Specialty.
Understanding of outpatient clinical practice and hospital medicine.
Valid California driver’s license and proof of current automobile insurance compliant with Partnership policy are required to operate a vehicle and travel for company business.
Advanced computer skills, including proficiency in multiple softwareapplications including Microsoft Office.
Ability to present data in local, concise manner.
Ability to analyze complex medical issues.
Must be able to work in a fast paced environment and maintain courtesy and composure.

Responsibilities

Performs Treatment Authorization Request (TAR) review and appeals to determine medicalnecessity, appropriateness of services, interprets benefits and limitations, and reviewsclaims, which are questionable in dollar amount or volume or scope of services. Assuresthat care is at all times at an acceptable level of quality.
Confers with and counsels participating physicians who have questionable patterns ofutilization.
Coordinates with Utilization Management department managers and directors to providedaily support and appropriate direction to staff on issues pertaining to UM.
Assists in developing and revising policies to support utilization management activities,including criteria and guidelines for appropriate use of services, clinical practice guidelinesand treatment guidelines.
Serves on Quality/Utilization Advisory Committee, Pharmacy & Therapeutics Committee,Credentials Committee and Internal Quality Improvement Committee as requested by theChief Medical Officer/ May work with community provider committees and Advisory boardson medical issues and policies.
Reviews potential quality issues and determines their appropriateness for review by thePeer Review Committee.
Advises the Grievances and Appeals Department on preparing for, and testifying, in StateFair Hearings.
Engagement of the Partnership provider network to improve quality of care and member experience.
Performs Pharmacy Authorization review and appeals to determine medical necessity and appropriateness of prescribed medications.
Acting as liaison to local Medical community
Other activities related to region assignment, as assigned.
Other duties as assigned.