Regional Medical Director | Focus on Patient Care with Optum
Primary Responsibilities: * Works primarily with the physician community around issues of patients, balancing business and clinical concerns. * Provides limited utilization management for outpatient medical, surgical and pharmacy activity. Participates in medical appeals activity. * Reviews all 2nd-level overturned cases related to medical necessity / investigational issues in the context of potential medical policy updates. Works with the Appeals area on appeals related to utilization management issues. * Provides medical leadership and physician advice to the quality management area with respect to quality improvement studies, quality improvement committees, primary care assessments (both office-site assessments and medical record document reviews). Performs peer reviews on quality complaints, sentinel events, and quality-of-care referrals. * Serves as Physician Advisor for other areas within the company, including but not limited to Sales and Marketing, Underwriting, PHP, and Provider Services. * Provides medical leadership and advice for conformance with standards and guidelines for NCQA, URAC, state and federal regulators, and other accrediting bodies. * Travel to multiple IPA offices in designated region to meet with teams, collaborate with Physicians, coach and educate to improve overall quality outcomes; efficiencies of care and initiatives.
Qualifications: * Possess a current and unrestricted MD or DO license in California * Board certification in Internal Medicine, Family Medicine, Pediatrics, Emergency Medicine * Minimum 3 - 5 years of experience working as a Medical Director in a managed care setting with minimum three years of experience in utilization management, utilization review and prior authorization. * **Minimum 3-5 years of experience interacting with both group and IPA Physicians including experience wit....
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Posted September 2, 2021