Essential Duties and Responsibilitiesinclude the following:
1.Understand, promote and manage with the principles of medical management to facilitate the right care at the right time in the right setting.
2.As part of a team of medical directors, nurses and coordinators, participate in the pre-service medical necessity review of patient care.
3.Review prior authorization requests for medical necessity with respect to Health Plans, CMS, third-party, (i.e., MCG, McKesson InterQual, American Imaging Management, and USPSTF), and medical group Medical Policies and Clinical Guidelines.
4.Perform internet searches for other existing policies/guidelines/medical necessity indications for requested services in order to facilitate quality, cost-effective care.
5.Identify high-risk patients and help coordinate care with the high-risk team.
6.In collaboration with the Lead Medical Director may identify needs for and participate in the development and implementation of Utilization Management/ Care Management policies and procedures to promote cost-effectiveness quality medical care.
7.Analyze and understand the major cost drivers related to various networks, lines of business, specialties, and individual providers. Will work with UM team to target specific cost drivers (provider, process, or service), create corrective plans in driving down costs educate/communicate with providers to implement changes in referral pattern, utilization, and management of patients, improve internal processes, study alternatives/new partnerships to provide better care.
8.From time to time, meet with individual PCP or specialist or provider group to review best practices, authorization requests and denials, utilization metrics and outcomes.
9.Participate/organize/chair UM team meetings to improve internal processes, team development and education.
10. Work closely with high risk and inpatient teams where care management paths intersect.
11. Will perform prior authorization function for a base campus/network and should need arise in cross coverage, secondary/tertiary review, or medical director decision making.
12. Perform retro-claims review for outpatient and inpatient.
13. Working with UM Director, participate, support, or take lead in audit processes both internal and external.
14. May participate in health plan joint operations meetings for discussions related to UM.
1.Work with network management team to establish and maintain provider relations.
2.Work with NM to grow and retain membership, focusing on patient satisfaction and ensuring members receive highest quality care in the most efficient and cost effective manner.
3.Travel and meet with IPA providers in their offices or at Town Halls to promote better relations, provide education and training, get feedback on the needs of the providers and their offices on medical management services, and implement changes to refine and grow network with ultimate goal to grow and retain membership.
4.In conjunction with the CMO and Lead Medical Director, hold quarterly meetings with contracted PCPs and specialists regarding performance metrics.
5.Identify "good" partners specialists and PCPs who are aligned with our goals of Triple Aim.
6.Assist in on-boarding new providers to the medical group on UM program, quality metrics, and network.
7.Be a direct resource to the IPA providers on issues related to UM and other aspects of patient care.
8.Understand contracts PCP, specialists, ancillary providers, hospitals, and vendors.
Quality/Grievance and Appeals:
1.Understand RMG/ADOC/Lakeside internal program for Q/G&A and from time to time, may review and respond to G&A and peer review.
2.Participate in meetings to review, develop, and continually improve internal QI/peer process and programs.
3.May perform verbal counseling to IPA providers after G&A determinations for corrective action plans and follow ups.
4.May write or review written counseling to IPA providers.
1.Doctor of Medicine or Doctor of Osteopathic Medicine degree.
2.Board certified, maintain board certification, active California license, and DEA privilege.
3.Specialty training preferred.
4.Minimum of five years of prior clinical experience required, with at least two years of managed-care or health-plan experience preferred.
5.Must demonstrate a strong clinical fund of knowledge.
6.Must have familiarity with the principles of clinical research and have the ability to interpret and apply clinical guidelines and policies.
7.Strong proficiency in MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point) and ability to conduct research over the internet.
8.Must have excellent communications skills both verbally and written.
9.Typing 50 words per minutes with accuracy preferred.
10. Ability to deal with responsibility with confidential matters.
11. Must have strong organization skills.
12. Ability to work in a multi-task, fasting moving environment.
13. 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.
14. Must be self-motivated, self-guiding, driven, and have high personal ethics.
15. 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.
16. Work as a member of the team.