Medical Director, Prior Authorization IE/San Diego

The Medical Director, Prior Authorization is responsible for actively participating in the review process of pre-service requests for services, and following guidelines in the approval of those services or in making recommendations for other determinations to the provider/vendor (denial/modification/redirection). Additionally, the role will cooperate with and support the other physician reviewers, nurses, and Medical Directors by knowing all processes and procedures, while working to deliver excellent care cost-effectively based on medical management referral processing guidelines. The Medical Director will be detail-oriented and able to research and successfully evaluate often-complex clinical information to help formulate decisions and communicate with members, providers, and internal users. Ideally, candidate would live in or near SD market to facilitate local provider network face-to-face engagement.. 60-90 auths/day depending on case complexity and additional time needed with peer-to-peers and general administrative duties. Understand, promote, and manage the principles of medical management to facilitate the right care for patients at the right time and in the right setting. As part of a team of medical directors, nurses, and coordinators participate in the pre-service medical necessity review of patient care. Review prior authorization requests for medical necessity using appropriate clinical guidelines. Identify high-risk patients and help coordinate care with the Employer’s high-risk team. From time to time, meet with individual primary care physicians, specialists, and/or provider groups to review best practices for patient care. Perform prior authorization functions for various Employer campuses, should the need arise in cross coverage, secondary/tertiary review, or medical director decision-making. Perform retroactive claims review for outpatient and inpatient care, as needed. Provider Relations Work with the Employer’s network management team to establish and maintain provider relations. Be a direct resource to the IPA providers on issues related to UM and other aspects of patient care. Quality/Grievance and Appeals Understand the Employer and its affiliates’ internal programs for Q/G&A and may review and respond to G&A and peer review. Participate in meetings to review, develop, and continually improve internal quality improvement and peer review processes and programs. Perform verbal counseling to IPA providers after G&A determinations for corrective action plans and follow-ups. Education and Experience Requirements Doctor of Medicine (MD) degree required. Specialty training and/or managed care experience preferred. Minimum of five years of clinical experience required. At least two years of managed care or health plan experience preferred. Skills and Qualifications Strong clinical knowledge with the ability to interpret and apply guidelines and policies. Familiarity with clinical research principles. High proficiency in MS Office (Word, Excel, Outlook, Access, PowerPoint) and internet-based research. Excellent verbal and written communication skills. Accurate typing skills (minimum 50 words per minute). Strong organizational abilities and attention to detail. Ability to manage multiple projects, prioritize effectively, and work well in high-pressure environments. Demonstrated integrity, self-motivation, and reliability in handling confidential information. Proven ability to collaborate with medical directors, department heads, and all management levels. Availability to attend on-site meetings and training sessions as required. The pay range for this position at commencement of employment is expected to be between $250,000/year- $300,000/year; however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, licensure, skills, and experience. The total compensation package for this position may also include other elements, including a sign-on bonus and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offered. Details of participation in these benefit plans will be provided if an employee receives an offer of employment. If hired, the employee will be in an “at-will position” and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors. Health and Wellness Employer-paid comprehensive medical, pharmacy, and dental for employees Vision insurance Zero co-payments for employed physician office visits Flexible Spending Account (FSA) Employer-Paid Life Insurance Employee Assistance Program (EAP) Behavioral Health Services Savings and Retirement 401 (k) Retirement Savings Plan Income Protection Insurance Other Benefits Vacation Time Company celebrations Employee Assistance Program Employee Referral Bonus Tuition Reimbursement License Renewal CEU Cost Reimbursement Program #J-18808-Ljbffr