Promotes and maintains appropriate care and utilization of services by implementing medical policy and complying with the contract requirements of each line of business (Medi-Cal and Cal MediConnect).
COMPLIANCE WITH REGULATIONS:
Works closely with all departments necessary to ensure that the processes, programs and services are accomplished in a timely and efficient manner in accordance with CHG policies and procedures and in compliance with applicable state and federal regulations including CMS and/or Medicare Part D, DHCS and DMHC.
Manage and control medical utilization by providing daily guidance and clinical supervision to the Health Care Services Division for prior authorization requests, formulary exception requests, concurrent review of inpatient and outpatient care, individual case management and behavioral health.
Leads Inter Disciplinary Care Team meetings and contributes to the Inter Disciplinary Care Plan when needed.
Maintain on-going communication and face-to-face contact with contracted providers.
Ensure all authorized services meet accepted criteria of medical necessity, are provided in an appropriate setting and at an appropriate level of care.
Review care with physicians and suggest alternative treatment plans when indicated.
Make recommendations about utilization management or contracting that will assist in the best use of medical services.
At the discretion of CMO, serve as backup for the Chief Medical Officer (CMO) and fulfill the responsibilities of the CMO in their absence.
Provide high quality customer service as integral member of Health Care Services team by
Helping UM and Case management teams meet turnaround time goals for utilization review and appeal decisions;
Participate in the development of clinical practice guidelines and utilization management criteria
Assist with the assessment of new and established medical technologies.
Assist, as may be requested by CMO from time to time, with activities of Credentialing, Peer Review, Pharmacy and Therapeutics and Quality Committees.
Help educate Health Care Services staff, as may be appropriate from time to time on clinical issues;
Establish and maintain a work environment that promotes high morale and performance; helps coordinate care with county and state health care programs (e.g., CCS and mental health).
Participate in special projects by assisting with preparations for NCQA accreditation survey as requested, internal and external audits, participating in committee meetings as requested; participating in risk management activities as requested; participating in other special projects as determined by the CMO.
Maintain product and company reputation and contributes to the team effort by conveying professional image and accomplishing related tasks; participating on committees and in meetings; performing other duties as assigned or requested.
Unencumbered California-licensed physician, preferably Board-certified in Family Practice or Internal Medicine.
Advanced training in medical management preferred.
Five years of clinical practice.
Minimum three years experience in medical management and managed care in a health plan setting.
Proficiency in keyboarding, ability to operate a personal computer and facility with learning and operating software applications (word processing, database, Excel spreadsheets, PowerPoint).
Knowledge of managed care principles.
Fluency with core principals of process improvement, continuous quality improvement, HEDIS measures.
Basic understanding of MediCal, Medicare and roles of respective regulatory agencies.
Bilingual and bi-cultural (English/Spanish) preferred.
Excellent interpersonal and communication, writing and presentation skills
Strong analytical, managerial and leadership skills.
Prolonged periods of sitting.
Traveling outside of San Diego County may be required.