About Us:
Santa Clara Family Health Plan (SCFHP) is a local, community-based health plan dedicated to improving the health and well-being of the residents of Santa Clara County. Working in partnership with providers and community organizations, we serve our neighbors through our Medi-Cal and SCFHP DualConnect (HMO D-SNP) health care plans.
About the role:
Responsible for the appropriateness and quality of care delivered through SCFHP and for cost-effective utilization of services. Responsible for Medi-Cal, and Medicare lines of business.
Day to Day:
- Performs treatment authorization review to determine medical necessity, appropriateness of services, and interpret benefits and limitations. Reviews that care is consistent with the Plan’s standards of quality.
- Participates in concurrent review activities of inpatient and long term care plans.
- Reviews claims that are unusual in cost, volume or scope of services.
- Acts as liaison between SFCHP and community providers, conferring and meeting as required.
- Coordinates with Directors of Medical Management and Quality Improvement to provide daily support and appropriate direction to staff on issues pertaining to UM and QI.
- Prepares and acts as a subject matter expert for all external and internal audits with regulators including: DMHC, CMS, DHCS, NCQA.
- Assists in developing and revising policies to support utilization management activities, including criteria and guidelines for the appropriate use of services clinical practice guidelines, and treatment guidelines.
- May serve on Quality Improvement Committee, Utilization Management Committee, Pharmacy and Therapeutics Committee, Credentialing Committee as requested by the Chief Medical Officer.
- The Medical Director may work with community provider committees and advisory boards on medical issues and policies.
- Reviews Potential Quality Issues and determines their appropriateness for review by the Peer Review Committee.
About You:
- Current unrestricted license to practice medicine in the State of California.
- Board Certified in a recognized medical practice specialty.
- Five years of post-residency experience in a recognized medical specialty.
- Specialty training in Family practice, internal medicine, or geriatrics is desired.
- One year utilization management experience for an Independent Practice Association, medical group or HMO.
- Working knowledge of HEDIS, NCQA standards, Medi-Cal Managed and Medicare.
- Knowledge of the Santa Clara County medical community.
- Experience in medical review systems.
Please review the full job description on our Career’s page:
https://phf.tbe.taleo.net/phf04/ats/careers/v2/viewRequisition?org=SANTCLAR2&cws=38&rid=3016
Job Type: Full-time
Pay: $238,916.00 - $382,265.00 per year
Benefits:
- 401(k) matching
- Dental insurance
- Employee assistance program
- Employee discount
- Flexible spending account
- Health insurance
- Life insurance
- Paid time off
- Referral program
- Retirement plan
- Tuition reimbursement
- Vision insurance
Application Question(s):
- Do you have experience with health plan core functionalities like UM, Appeals, PA, also well versed in Population Health management, Quality improvement, knowledge of Value based care programs?
- Do you have one year utilization management experience for an Independent Practice Association, medical group or HMO?
Education:
Experience:
- Family medicine: 5 years (Required)
License/Certification:
- Medical License (Required)
Work Location: Hybrid remote in San Jose, CA 95119