Medical Director, Utilization Management - Concurrent Review

Your Role

The Medical Director, Utilization Management - will report to the Sr. Medical Director, Utilization Management. In this role you will deliver and collaborate on clinical review activities, which includes management of the physician processes in support of utilization management and transactional functions for membership.

Your Knowledge and Experience

• Medical degree (M.D./D.O.)
• Completed residency preferably in adult based primary care specialty (e.g. internal medicine, family practice)
• Maintain active, unrestricted California State Medical License required; Maintain active, unrestricted Medical License in all additional assigned states required
• Maintain Board Certification in one of ABMS or AOA categories required (preferably Internal Medicine or Family Practice)
• Minimum 5 years direct patient care experience post residency
• Demonstrated proficiency in at least 3 of the following: Medicare/Medicare STARS, Dual Special Needs Plan (D-SNP), Medi-Cal, NCQA/URAC/Quality Programs, Policies/Procedures development, Clinical Subject Matter Expert for Litigation, SIU/Waste/Fraud/Abuse, Appeals/Grievances, Case Management/Population Health, Federal Employee Program (FEP), Education/Training (delivers CME, CEU), Quality Improvement
• Knowledge of Medicare, California statutes and regulations including DMHC. Understanding of NCQA accreditation standards preferred
• Knowledge and skilled application of National evidence-based medical necessity criteria references (MCG or InterQual)
• An ability to work independently to achieve objectives and resolve issues in ambiguous circumstances