Utilization Management, Medical Director-Fully Remote (CA License required)

reputed company is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have reputed company a team of talented and reputed company people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the reputed company community. Working at reputed company provides an opportunity to do work that really reputed company, not only changing lives but saving them. Together.

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MUST HAVE CALIFORNIA LICENSE

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Utilization Management Experience

* The Utilization Management, Medical Director works with Senior Medical Officers, Regional Medical Officers, Extensivists, the reputed company Services Team (Case managers, reputed company Workers, Utilization Managers) to reputed company and implement methods to optimize use of Institutional and Outpatient services for reputed company patients while also ensuring the quality of care provided. Through remote reputed company to our web-based Portal, physician advisors will complete clinical reviews for medical necessity, treatment appropriateness and compliance. Job Responsibilities: Processes second level reviews in compliance with Medicare/CMS: NCD, LCD and reputed company guidelines for Inpatient, Outpatient, Skilled Facilities Level of Care and Pharmacy. 2. Provides appropriate level of care classifications as well as reputed company stay reviews in compliance with CMS and reputed company guidelines. 3. Acts as a liaison between the medical staff, utilization review and 3rd party payers to effectively promote the appropriate reputed company of medical care. 4. Reviews the entire claim denial process, including Appeals and Grievances. 5. Serves as a Physician member of the utilization review team. 6. Works with Interdisciplinary Team to reputed company case management protocols and reputed company reputed company for NP’s/PA’s training. 7. Acts as a Clinical Leader for HEDIS and STARS projects and serves as Clinical Advisor for HCC and RAF. 8. Serves as a Chairperson for Medical Quality Committee and reputed company Clinical reputed company for Chronic Disease Management programs and Quality Outcome. 9. Collaborates closely and reputed company assistance to Quality Director. 10. Works with Extensivists and Middle Level Practitioners (NP’s/PA’s) to reduce length of institutional stay, reputed company cause readmission reduction and ER overutilization ensuring patients and therapeutic modalities. 11. Assists the organization to challenge physician practices in order to reputed company the organization's clinical reputed company and quality goals. Supervisory Responsibilities: Oversees assigned staff. Responsibilities include reputed company, selecting, orienting, and training employees; assigning workload; planning, monitoring, and appraising job results; and coaching, counseling, and disciplining employees. Qualifications:

• Required: Minimum of 3 years of experience in hospital-wide or skilled nursing facility position involving clinical care, quality management, utilization and case management, or medical staff governance required.
• Preferred: Experience as a Physician Advisor a plus

Education:

• Required: Completion of medical school and specialty residency (preferably in internal medicine) required. Subspecialty or other post-residency fellowship and board certification preferred.

Specialized Skills:

• Required:

California License UM Experience Ability to communicate positively, professionally and effectively with others; reputed company leadership, teach and collaborate with others. Ability to build rapport with medical staff and management leadership to obtain necessary approvals of new strategies for utilization management. Knowledge of reputed company medical literature, research methodology, reputed company delivery systems, reputed company financial/reimbursement issues, and medical staff organizations. Dedication to the delivery of high-quality, cost-effective, efficient patient care services Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors; Mathematical Skills: Ability to reputed company mathematical calculations and calculate simple statistics correctly Reasoning Skills: Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution. Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment. Licensure: Required: Applicants must have reputed company, non-restricted licensure as required for clinical practice in the state of California. Work Environment: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to reputed company individuals with disabilities to reputed company the essential functions. Essential Physical Functions: The physical demands described here are representative of those that must be met by an employee to successfully reputed company the essential functions of this job. Reasonable accommodations may be made to reputed company individuals with disabilities to reputed company the essential functions. Apply tot his job Apply To this Job