Medical Director, Utilization and Medical Management

You Will Focus On:

• The Medical Director plays a vital role in both the development and implementation of Utilization Management policy and procedures. This physician is chosen based upon their knowledge of medical practice, experience in Managed Care, Utilization, Quality Management programs and an ability to interact well with the other physicians.
• Works to continually enhance the overall efficiency and quality of care for patients served by One Altais through effective network management.
• Develop and maintain collaborative functioning relationships with key providers, particularly thought leaders, across the One Altais service delivery footprint.
• The Medical Director will provide cooperative leadership and direction to the UMC (Utilization Management Committee) Primary Care Physicians (PCP) and all Specialist Physicians as assigned by the Senior Medical Director.
• The Medical Director may be asked to co-chair several committees including the Utilization Management Committee, The Quality Management Committee, the Peer Review and Patient Safety Committee, and others as needed.
• The Medical Director may be responsible for interfacing with health plans regarding benefits, coverage issues, response to appeals, attend HMO hearing on appeals and administrative issues which cannot be settled by the Case Managers and/or Management.
• The Medical Director will work closely with physician leaders across all healthcare settings to ensure that patient care is managed in a cost containment manner without compromising health outcomes.
• This physician leader will facilitate clinical rounds with the Case Managers & Management to ensure bed day performance goals are met.
• Collaborate with the Senior Medical Director and Chief Office for Health and Innovation to engage network physicians with regard to performance, cost, clinical appropriateness and authorizations.
• This individual takes an active role in the development and promotion of managed care systems within One Altais. This will include development of UM policies and procedures, identifying the type of criteria to be used for authorization review, and implementation of a regular forum in which to educate PCPs and specialists on utilization management systems.
• The Medical Director also serves as an important resource and key contact for identified case management problems and participates in IDCT (Interdisciplinary Care Team) Meetings.
• The Medical Director supports the Senior Medical Director as a resource person for Physician Education on UM and input into the One Altais UM goals and objectives.
• Coordination of prospective, concurrent, retrospective review including denial and/or approval of all outside medical services referrals as necessary.
• Develop and maintain written medical care protocols and assure UM Standardization.
• Chart Reviews for Appropriateness of applying clinical guidelines.
• Physician to Physician liaison for UM related issues.
• Prepare and review Decision Validation Criteria as required by UM.
Required Meetings:
• UM Committee
• Health Plan Joint Operations Meetings
• Hospital Joint Operations Meeting
• One Altais Meetings involving Utilization Management

The Skills & Experience You Bring

• Strong clinical skills
• Knowledge of utilization management techniques
• Strong interpersonal and communication skills.
• Must have a demonstrated ability to secure the trust and confidence of employees at all levels, in a manner that assures an effective, open and productive working relationship.
• Must be effectively and confidently able to provide advice and expertise as a medical professional, and stay abreast of changes, innovations, and trends in the industry.
• Doctor of Medicine degree; valid California licensure; Current Board certification, preferably in a broad based specialty such as Internal Medicine, Family Practice, Emergency Medicine, Geriatrics, General Surgery or Pediatrics.
• A minimum of seven years as a practicing inpatient and outpatient physician in a managed care environment with 10+ years preferred.
• Utlization management and medical management experience.

You Share Our Mission & Values:

• You are passionate about improving the healthcare experience and want to be part of the Altais mission.
• You are bold and curious- willing to take risks, try new things and be creative.
• You take pride in your work and are accountable for the quality of everything you do, holding yourself and others to a high standard.
• You are compassionate and are known as someone who demonstrates emotional intelligence, considers others when making decisions and always tries to do the right thing.
• You co-create, knowing that we can be better as a team than individuals. You work well with others, collaborating and valuing diversity of thought and perspective.
• You build trust with your colleagues and customers by demonstrating that you are someone who values honesty and transparency.