Medical Director, Medical Management
Not Disclosed•Full-TimeOn-site
location_on2925, H Street, Marshall School, East Sacramento, Sacramento, Sacramento County, California, 95816, United States
About the Role
As a physician within a multidisciplinary team, you will ensure that utilization management responsibilities are performed in accordance with the highest and most current clinical standards. Your primary focus involves reviewing escalated cases electronically against Medical Policy criteria to evaluate the medical necessity and appropriateness of requested treatments or services. Depending on the complexity of the case, you will engage in telephonic peer-to-peer discussions to facilitate these decisions.
Beyond individual case reviews, you will serve as a vital physician member of the Case and Disease Management (CMDM) multidisciplinary team. In this capacity, you will advise the team on complex cases, particularly those involving high-risk patients, ensuring that all medical management processes align with community standards of care. You will also contribute to the development of protocols and guidelines to maintain consistency in the review process and may be assigned special projects aimed at improving the overall care of our members.
Compliance and Standards
This role requires strict adherence to all relevant regulatory frameworks, including NCQA, URAC, CMS, DOH, and DOL regulations. You will be responsible for composing clear and concise rationales for member and provider determination notifications while maintaining full compliance with these standards. Additionally, you will ensure that all aspects of the medical management process reflect the ethical and legal standards set forth in the company's code of business conduct, including strict adherence to HIPAA and data security guidelines regarding confidential customer information.
Work location
Work model: On-site
2925, H Street, Marshall School, East Sacramento, Sacramento, Sacramento County, California, 95816, United States
Sacramento, California
Key Responsibilities
- check_circleConduct electronic review of escalated cases against medical policy criteria to determine medical necessity
- check_circleCompose clear rationales for member and provider determination notifications while adhering to compliance standards
- check_circleParticipate as a physician member of the multidisciplinary team to advise on high-risk cases
- check_circleParticipate in protocol and guidelines development to ensure consistency in the review process
- check_circleManage special projects to support and improve member care
- check_circleReview appeals and grievances and complete initial case determinations
- check_circleEngage in telephonic peer-to-peer discussions to evaluate treatment appropriateness
Requirements
- verifiedMedical Doctor (MD) or Doctor of Osteopathic Medicine (DO)
- verified5 years in Clinical, Direct Patient care
- verifiedBoard Certification recognized by ABMS or AOA
- verifiedActive medical state licensure
Nice to Have
Master's Degree in Business Administration/Management or Public Health. 1 year in Medical Management in a Health Insurance Plan with strong knowledge of the managed care industry.
