Imperial Management Administrators Services
The Medical Director is directly responsible for overseeing the clinical managed care functions related to utilization management, quality management and other areas deemed appropriate by the CEO. This is an on-site position in Pasadena, CA.
- Medical Degree from an accredited Medical School and subsequent family practice or internal medicine residency training program, preferred.
- At least 3 years’ experience as a clinician.
- Assists in providing leadership, direction, and oversight for all managed care clinical operations including Utilization Review, Quality Oversight, and Special Referral Management.
- Provides clinical leadership and oversight to the Utilization Management and Quality Oversight teams responsible for concurrent review and retrospective review for hospital admissions, prior authorizations for select services, pharmacy case reviews, care coordination, nurse advice line, denial processes, member clinical appeals, regulatory compliance, quality management, provider credentialing and re-credentialing, health education and culture to comply with contract requirements and State Department of Health Care Services regulatory criteria.
- Ensures consistency of and adherence to managed care clinical.
- Escalates key issues and work to resolve to maintain contract compliance and responsiveness to internal and external customers.
- Works with other leadership to ensure overall compliance with State and managed care payer contracts, State Department of Managed Health Care and all relevant managed care rules and regulations.
- Chairs any Utilization Management and Quality Oversight, and Credentialing Committees.
- Reviews clinical cases, clinical grievances, and appeals as needed.
Writes, interprets and communicates clinical policies, procedures and priorities internally and to various agencies in the community.
- Assists with the development and implementation of programs that promote professional growth, executive and physician leadership development, and job satisfaction of staff.
- Outstanding clinician with strong clinical references.
- Excellent verbal and business written communication skills (both for clinicians and non-clinicians).
- Excellent leadership skills to provide strategic planning.
- Ability to handle varying situations efficiently with tact and diplomacy.
Experience in managed care functions such as: utilization management, grievances/appeals, credentialing, case management, or network management.
Experience with public insurance programs, such as, Medi-Cal and Medicare.
LICENSURE AND CREDENTIALS:
Current and unrestricted license by the Medical Board of CA to practice medicine in the state of California, license in state of Texas a PLUS
- Provide medical oversight and direction for clinical programs and services, assure that required primary care and mental health services are available to patients and supervise care given by clinic staff.
- Maintain responsibility for quality of clinical care, including adherence to generally accepted medical practices.
- Works with senior management team in development of a high-quality clinical information system that includes thoroughly documented medical records, tracking of referral, recall of patients, maintenance of Quality Improvement (QI) program, and assessment of clinical outcomes.
- Actively participates in budget, cost containment and productivity efforts, including participation in planning and budgeting process with CEO and CFO and Board of Directors to identify opportunities, priorities, goals, and objectives of health care.
- Provides clinical leadership and actively supports and participates in chronic disease collaborative(s) and/or other re-engineering and quality improvement efforts, including testing, implementation, and oversight of changes, as appropriate.
- Participate in the hiring of licensed personnel. Recommend hiring and other disciplinary actions of medical staff for review and approval by the CEO.
- Update and implement bylaws, policies and procedures related to the medical staff and the credentialing and appointment/reappointment process.
- Participate in the evaluation of and periodic review of all members of the medical staff. To include denial language support for inpatient, outpatient, and pharmacy determinations.
- Work closely with clinic staff to review and agree on CQI standards; participate in continuous quality improvement activities; supervise the quality assurance/risk management program; includes review of services, quality, patient satisfaction, utilization, peer review, provider productivity, infection control and other clinical issues.
- Perform periodic reviews of quality management plans and make recommendations for modifications and improvements.
- Review hospitalization and discharge planning and patient tracking activities.
- Work closely with staff in Appeals & Grievance Unit for reviewing potential quality of care cases and assist in determining severity of level.
- Review medical necessity appeals and make determination whether to uphold or overturn the denials.
- Advocates for the clinic and serves as a liaison to local, state, and federal health care agencies as appropriate.
- Member of Credentials Committee
- Chair Ad hoc Committee as needed
- Approve credential/re-credential applications for membership
- Review Level 2 applications
To apply for this job please visit forms.office.com.