Required Skills & Education:
- Current unrestricted license to practice medicine in the State of California.
- Board Certified in a recognized medical practice specialty.
- 5 years of post-residency experience in a recognized medical specialty.
- One year utilization management experience for an Independent Practice Association, medical group or HMO.
- Knowledge and experience with MediCal and Medicare.
- Experience in medical review systems.
- Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word, Excel, and PowerPoint.
Responsibilities
- 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.
- 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.
- Performs Pharmacy Prior Authorization review in support of the Pharmacy Director
- Participates in the Grievance and Appeal process as required, including performing second-level reviews of previous denials.
- Participates in and leads special projects and assignments as requested.
#INDPM
Job Types: Part-time, Contract
Pay: $130.00 - $150.00 per hour
Expected hours: 20 per week
Benefits:
- 401(k)
- Dental insurance
- Flexible schedule
- Health insurance
- Life insurance
- Paid time off
- Vision insurance
Schedule:
- 8 hour shift
- Choose your own hours
- Day shift
- Monday to Friday
License/Certification:
- Medical License (Required)
Location:
Work Location: Remote