Medical Director, Utilization Management - FEP

Your Role

The Medical Director is a key member of the Medical Management team within the Healthcare Quality and Affordability business unit. This is a front-line utilization management position that has core responsibilities in the areas of inpatient concurrent review, pre and post service utilization review, and collaboration with RN Case and disease managers. This director position will report to the Sr. Medical Director, Medical Management.

Your Knowledge and Experience

• Medical degree (M.D./D.O.)

• A minimum of 3 years of experience working for a Medical Group, IPA, or Health Plan making decisions for Medicare Advantage utilization is preferred but not required.

• A minimum of 5 years direct patient care experience post residency.

• Active recent hospital experience (within the past five years) is desirable. Strong clinical skills with prior experience in a primary care setting.

• A medical degree (MD or DO) with 5 or more years of clinical experience, preferably in a managed care setting with hospital experience, since a large part of this position involves inpatient con-current review.

• 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 recognized specialty required (preferably Internal Medicine or Family Practice)

• Demonstrated proficiency in at least three of the following:

  • MEDICARE/MEDICARE STARS

  • Dual Special Needs Plan (D-SNP)

  • MEDI-CAL

  • NCQA/URAC/Quality Programs

  • Policies/Procedure 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