Physician / Administration / California / Permanent / Health Plan Medical Director Job

1. Develop and implement medical policy for utilization management activities and functions, including benefit manual statement, policies and procedures, and Utilization Management Subcommittee Guidelines. Provide training and consultation for both internal staff and medical personnel of the Plan regarding policy application.2. Provide direction and control of current medical practices ensuring that medical personnel of the Plan follow medical protocols and rules of conduct.3. Ensure assigned patients are provided healthcare services and necessary medical attention at all locations.4. Collaborates with Contracting Department to ensure full and appropriate primary, specialty, and ancillary care network adequacy for Members.5. Ensures that medical decisions are rendered by qualified medical personnel, unhindered by fiscal or administrative management. Provides clinical oversight and direction over credentialing process.6. Ensures that medical care rendered by providers meets with applicable professional standards for acceptable medical care and quality.7. Consults on written medical protocol for Plan physicians to ensure adherence to current standards and quality of medical care. Coordinates professional interactions among practitioners and lends assistance toward correcting any deviation from medical standards.8. Interacts regularly with inpatient hospitalist groups, PCP & specialists to ensure appropriate medical care is provided and utilization standards are met.9. Develops and manages a formal Utilization Management Program for the Plan and its Providers. This Program includes protocol, procedures, oversight, and training in the following areas: a. Provider Selection b. Credentialing c. Peer Review Activities d. Referral Management e. Pre-admission authorization f. Prospective, concurrent, and retrospective review g. Utilization review reporting and evaluation h. Case Management i. Provider Incentive Programs j. Chairperson/ Co-Chair of the HEDIS Improvement Committee, Quality Management Committee, Quality Improvement Committee, Credentialing Committee, Grievance Trend Committee k. Participates on the Pharmacy and Therapeutics Subcommittee l. NCQA Accreditation.10. Act as a liaison to Provider Relations as a link between IEHP and individual physician, IPAs, medical groups, and hospitals.11. Adjudicate medically related grievances and appeals that flow through the Member grievance and appeals process.12. Review State mandated benefits to ensure IEHP is in full compliance through its Providers.13. Assist Compliance on sanctioned and excluded Provider management. Responsibilities include oversight of safe transitions of care for Members and communication with regulatory agencies and impacted departments (e.g., Pharmacy, Claims, Care Management, Utilization Management, etc.).14. Provide physician level guidance on organizational improvement initiatives, including LEAN activities and Process Improvement Team projects.