Medical Director of Utilization Review and Managed Care (MD or DO)- Los Angeles Area

HireFlux - Los Angeles, CA (30+ days ago)

Our Firm, HireFlux, has Been Retained to Recruit an experienced Managed Care Medical Director

  • Managed Care Company. Experience with Medicare and Medicaid is crucial. Will report to Medicare Executive Director
  • Manages day-to-day quality improvement and medical management activities.
  • Establishes and is accountable for health plan utilization, OS applications and quality outcomes.
  • Assures all internal and vendor medical review activities conform to company protocols, customer requirements, and professional standards.
  • Ensures adherence to assigned budget accountabilities.
  • Works closely with other medical directors and clinical services staff to attain and/or maintain compliance with company, customer, accreditation and regulatory requirements.
  • Manages the application of all clinical aspects of the Credentialing Program, Credentialing Committee and Peer Review activities at the state level.
  • Shares responsibility for quality improvement and accreditation initiatives in the assigned market(s)
  • Develops value propositions for clinical programs through quantitative analytics, ROI and evidence-based data
  • Initiates dialogue with providers, as necessary, to resolve differences in opinions concerning utilization management. Reviews and makes determinations regarding provider appeals.
  • Ensure compliance with federal, state and NCQA standards
  • Oversees provider education regarding pharmacy, utilization, quality improvement and responsible health care expenditures to improve clinical outcomes
  • Establishes and maintains relationships with key stakeholders in partnership with the market leadership
  • Provides medical accountability in fulfilling the company’s compliance with customer audits and reports, and accreditation surveys.
  • A Doctor in Medicine (MD or DO) required
  • Completion of US Residency required
  • Board Certification required
  • 5+ years of experience in direct patient care is required.
  • Substantial experience and expertise in the development of medical policies, procedures and programs is required.
  • Demonstrated success implementing utilization and quality improvement strategies /techniques and experience with physician behavior modification is required.
  • Qualifications to perform clinical oversight for the services provided by the health plan to include but not limited to education, training or professional experience in medical or clinical practice is preferred.
  • Past participation in a managed care UM committee
We are actively interviewing!

If this is something of interest to you or anyone you know, please respond with your CV and the best phone number/time to reach you. I look forward to speaking with you!

Ashliegh Dumont

Director of Physician Recruitment and Client Development

Keywords: Family Medicine, Medicare, Medicaid, Managed Care, Family Practice, Internal Medicine, Pediatrics, Internist, Hospitalist, Board Certified, MD, DO, Medical Doctor, Utilization Review, Medical Director, Senior Medical Director