Medical Director, Prior Auth IE/San Diego

Medical Director

The Medical Director is responsible for actively participating in the review process of pre-service requests for services, and following guidelines in the approval of those services or in making recommendations for other determinations to the provider/vendor (denial/modification/redirection). Additionally, the role will cooperate with and support the other physician reviewers, nurses, and Medical Directors by knowing all processes and procedures, while working to deliver excellent care cost-effectively based on medical management referral processing guidelines. The Medical Director will be detail-oriented and able to research and successfully evaluate often-complex clinical information to help formulate decisions and communicate with members, providers, and internal users.

Prior Authorization

• Understand, promote, and manage the principles of medical management to facilitate the right care for patients at the right time and in the right setting.
• As part of a team of medical directors, nurses, and coordinators participate in the pre-service medical necessity review of patient care.
• Review prior authorization requests for medical necessity using appropriate clinical guidelines.
• Identify high-risk patients and help coordinate care with the Employer's high-risk team.
• From time to time, meet with individual primary care physicians, specialists, and/or provider groups to review best practices for patient care.
• Perform prior authorization functions for various Employer campuses, should the need arise in cross coverage, secondary/tertiary review, or medical director decision-making.
• Perform retroactive claims review for outpatient and inpatient care, as needed.

Provider Relations

• Work with the Employer's network management team to establish and maintain provider relations.
• Be a direct resource to the IPA providers on issues related to UM and other aspects of patient care.

Quality/Grievance and Appeals

• Understand the Employer and its affiliates' internal programs for Q/G&A and may review and respond to G&A and peer review.
• Participate in meetings to review, develop, and continually improve internal quality improvement and peer review processes and programs.
• Perform verbal counseling to IPA providers after G&A determinations for corrective action plans and follow-ups.

The pay range for this position at commencement of employment is expected to be between $250,000/year- $300,000/year; however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, licensure, skills, and experience.

The total compensation package for this position may also include other elements, including a sign-on bonus and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offered.

Details of participation in these benefit plans will be provided if an employee receives an offer of employment.

If hired, the employee will be in an "at-will position" and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.

As one of the fastest-growing Independent Physician Associations in Southern California, Regal Medical Group, Lakeside Community Healthcare & Affiliated Doctors of Orange County, offers a fast-paced, exciting, welcoming, and supportive work environment. Opportunities abound, and enterprising, capable, focused people prosper with us. We promote teamwork, nurture learning, and encourage advancement for all of our employees. We want to see you excel, because we believe that your success is our success.

Full-Time Position Benefits:

The success of any company depends on its employees. For us, employee satisfaction is crucial not only to the well-being of our organization but also to the health and wellness of our members. As such, we are firmly dedicated to providing our employees the options and resources necessary for building security and maintaining a healthy balance between work and life.

Our dedication to our staff is evident in our comprehensive benefits package. We offer a very generous mixture of benefits, including many employer-paid options.

Health and Wellness:

• Employer-paid comprehensive medical, pharmacy, and dental for employees
• Vision insurance
• Zero co-payments for employed physician office visits
• Flexible Spending Account (FSA)
• Employer-Paid Life Insurance
• Employee Assistance Program (EAP)
• Behavioral Health Services

Savings and Retirement:

• 401 (k) Retirement Savings Plan
• Income Protection Insurance

Other Benefits:

• Vacation Time
• Company celebrations
• Employee Assistance Program
• Employee Referral Bonus
• Tuition Reimbursement
• License Renewal CEU Cost Reimbursement Program
• Business-casual working environment
• Sick days
• Paid holidays
• Mileage

Employer will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of the LA City Fair Chance Initiative for Hiring Ordinance.

1. Doctor of Medicine degree.
2. Specialty training and/or managed care experience preferred.
3. Minimum of five years of prior clinical experience required, with at least two years of managed-care or health-plan experience preferred.
4. Must demonstrate a strong clinical fund of knowledge.
5. Must have familiarity with the principles of clinical research and have the ability to interpret and apply clinical guidelines and policies.
6. Strong proficiency in MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point) and ability to conduct research over the internet.
7. Must have excellent communication skills, both verbal and written.
8. Typing 50 words per minute with accuracy.
9. Ability to deal responsibly with confidential matters.
10. Must have strong organizational skills.
11. Ability to work in a multi-task, high-stress environment.
12. Must be able to handle multiple projects at one time, reset priorities day-to-day to meet deadlines, and know when to ask for assistance and direction when working with conflicting priorities.
13. Must be self-motivated, self-guided, driven, and have high personal ethics.
14. Must have the ability to work with all levels of management and have the ability to develop positive working relationships with medical directors and company department heads.
15. Must be able to come on-site to department meetings /trainings when needed.