Regional Medical Officer - SCMG - Sharp Corporate - Day Shift - Full Time

Sharp HealthCare•San Diego, CA

23h•$125 - $197

About The Position

The position is accountable for providing medical management and leadership to SCMG to ensure the delivery of high quality, customer responsive and cost-effective medical care on behalf of SCMG, and its members through a network of private practice physicians.

Requirements

5 Years clinical practice experience.
California Physicians and Surgeons License - Medical Board of CA - REQUIRED
Must be Board Certified.
In-depth knowledge of medical care delivery systems, utilization management, quality assurance, peer review, contracting, benefits interpretation, provider relations, and member services.
Excellent interpersonal and persuasive communications skills along with leadership skills.
Knowledge and experience in the operations of a prepaid delivery system.
Ability to manage for results and good analytical and negotiation skills.

Responsibilities

Participation in Health Services Management including: Authorization or denial of hospital admissions and extended stays.
Daily on-site review of the medical necessity of inpatient hospital stays with ongoing interaction with admitting physicians and/or hospitalists and concurrent review staff.
Authorization or denial of outpatient procedures.
Review of out of area hospital and medical care services, and out-of-network department patient management.
Interaction with case management activities.
Provides input on medical claims review to determine medical necessity, appropriateness of provider services, interpretation of benefits and limitations, and review of claims.
Provides input on day-to-day medical care review on issues involving prior authorization, concurrent review and retrospective review of outpatient and inpatient services.
Participates in and performs benefit interpretation and criteria development.
Communicates with health plan clients and medical directors on utilization function.
Identifies physicians whose utilization and/or clinical practices are aberrant and recommends and participates in taking corrective action in both inpatient and outpatient settings. This includes education of participating physicians regarding medical group policies and procedures and monitoring of physician compliance.
Develops and implements physician sanction and grievance procedures in coordination with the Executive Medical Director and Chief Medical Officer.
Communicates directly with providers regarding problem resolution of grievances.
Participates with systems integration of mutual utilization review and finance issues related to appropriate level and location of patient services.
Provides medical knowledge, management and resource to assigned regional councils, specialty advisory councils and other SCMG committee meetings as assigned and mutually agreed upon by other SCMG medical directors.
Participates with the other medical groups within the Sharp medical community to achieve efficiencies of operation whenever appropriate.
Active participation in regional hospital operations meetings.
Close “supervision” of the hospitalist team.
Provision of performance data, feedback, etc., needed to ensure improvement of hospital utilization.
Identification of low hanging fruit for improved management, i.e., pain management.
Other duties as assigned.