Medical Director Utilization Management

The purpose of Dignity Health Management Services Organization (Dignity Health MSO) is to build a system-wide integrated physician-centric full-service management service organization structure. We offer a menu of management and business services that will leverage economies of scale across provider types and geographies and will lead the effort in developing Dignity Health’s Medicaid population health care management pathways. Dignity Health MSO is dedicated to providing quality managed care administrative and clinical services to medical groups hospitals health plans and employers with a business objective to excel in coordinating patient care in a manner that supports containing costs while continually improving quality of care and levels of service. Dignity Health MSO accomplishes this by capitalizing on industry-leading technology and integrated administrative systems powered by local human resources that put patient care first.

Dignity Health MSO offers an outstanding Total Rewards package that integrates competitive pay with a state-of-the-art flexible Health & Welfare benefits package. Our cafeteria-style benefit program gives employees the ability to choose the benefits they want from a variety of options including medical dental and vision plans for the employee and their dependents Health Spending Account (HSA) Life Insurance and Long Term Disability. We also offer a 401k retirement plan with a generous employer-match. Other benefits include Paid Time Off and Sick Leave.

***This position is remote within California, Nevada or Arizona, with a current State of California physician license.

***Please note, this position is part-time, 20 hours per week, and will be expected to work within PST business hours.

Position Summary:

The Medical Director of UM reports to the Chief Physician Executive (CPE) and is responsible for providing clinical expertise and business direction in support of medical management programs that promote the delivery of high quality, consistent responsive medical care. Will ensure services provided to patients are medically necessary, efficient and in accordance with regulatory requirements.
Provides technical expertise in medical management by direct decision making in the areas of: prior authorization, concurrent review of hospitalized patients, discharge planning management. This position is responsible for all UM and associated QM activities including, but not limited to developing clinical guidelines, measuring adherence to guidelines, and communicating utilization and quality concerns on specific cases to the provider network.
In this role you will provide leadership oversight to medical physician reviewers and network medical directors who support UM reviews, ensuring consistency, quality and compliance in UM activities. This will include but not be limited to standardization of prior authorization reviews, coordinating coverage for vacations, holidays and weekends as necessary to maintain regulatory compliance of UM functions.

Minimum Qualifications:

- Minimum of 10 years of clinical experience in a HMO/Managed Care setting; and a minimum of 5 years with oversight of clinical staff required.
- Licensed physician in the State of California, Board Certified in Internal Medicine or Family Practice preferred. License without restrictions to practice and free of sanctions from Medicaid or Medicare.
- Must have Medicaid and/or Medicare knowledge and experience.
- Demonstrated leadership, ability to build effective teams and structure, decision making, project management and change management skills.
- Knowledge of NCQA, HEDIS, Medicare and Pharmacy benefit management, Group / IPA practice, capitation, HMO regulations, managed healthcare systems, quality improvement, medical utilization management, risk management, risk adjustment, disease management, evidence-based guidelines, and current clinical knowledge.

Preferred Qualifications:

- Minimum of 10 years+ of clinical experience in a Utilization Management setting preferred
- Board Certified in Internal Medicine or Family Practice preferred. Additional competence in geriatrics or special needs populations is desirable. Special extended expertise in at least one of these areas is desirable.

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