Medical Director

Health Partners Plans, Inc.; San Francisco (CA); Remote; USD 100,000 - 200,000; Full time

Job summary

An established industry player is seeking a dedicated Medical Physician to join their HealthCare Management team. This role is pivotal in ensuring the effective delivery of medically necessary services through utilization management, care management, and pharmacy services. You will leverage your clinical expertise to advocate for patients while collaborating with various stakeholders to optimize healthcare outcomes. With a focus on continuous improvement, you will support accreditation processes and develop guidelines for care. If you are passionate about enhancing healthcare delivery and possess strong leadership and analytical skills, this opportunity is perfect for you.

Qualifications

• 5+ years post-residency experience in clinical practice required.
• Managed care experience with responsibility for utilization management.

Responsibilities

• Perform utilization review for various service requests.
• Advise senior management on effective healthcare service delivery.
• Develop and implement policies for effective utilization management.

Skills

Organizational Skills

Interpersonal Skills

Time Management Skills

Communication Skills

Leadership Skills

Conflict Resolution Skills

Decision-Making Skills

Project Management

Negotiation Skills

Analytical Skills

Education

Medical Physician (MD or DO)

Pennsylvania Medical License

Board Certification in a specialty

Graduate business degree (MBA, MMM, etc.)

Tools

Excel

Access

Word

Job description

Job Details

Function as an integral part of the HealthCare Management team responsible for Utilization Management, Care Management, and Pharmacy Services programs. Represent HealthCare Management in interdepartmental activities and represent Health Partners in the hospital/health system and provider communities and regulatory and governmental activities. Apply clinical expertise and experience as a provider to promote the proper delivery of medically necessary services to the population served. Perform utilization, pharmacy, and quality reviews.

Job Description

Essential Functions:

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Perform utilization review for requests for services including but not limited to inpatient, outpatient, pharmacy and dental. This will include peer-to-peer discussions with providers.
• Serve on and support the functions of committees including but not limited to the Utilization Management Committee and Pharmacy & Therapeutics Committee.
• Advise the HealthCare Senior Management team regarding the utilization of health care services and interventions to promote the effective delivery of medically necessary services.
• Participate and/or lead rounds including but not limited to disease management, care management or admissions.
• Provide support for Plan accreditation processes (NCQA), Utilization, Quality and Disease Management programs.
• Support ongoing activities in OB, pediatric, adolescent, adult preventative, and geriatric care.
• Develop and or revise practice guidelines for acute and chronic care.
• Develop and implement policies and procedures required to promote effective utilization management and achieve established targets.
• Collaborate with HealthCare Economics and Finance to continuously improve the collection and use of data describing resource utilization and outcomes.
• Represent HealthCare Management internally and externally at the direction of the VP Chief Medical Officer.
• Develop and implement work plans to optimize appropriate utilization and quality targets as directed by the VP Chief Medical Officer.
• Perform other job duties as assigned.

Work from Home

This position is available to work from home.

Required Education and Experience:

• Medical Physician (MD or DO) required.
• Pennsylvania Medical License without restriction.
• Board Certification in a specialty (primary care preferred).
• Graduate business degree is a plus (MBA, MMM, etc.).
• Minimum 5 years post-residency experience in the clinical practice of medicine.
• Managed care experience, with responsibility for utilization management.

Skills/Abilities:

• Excellent organizational, interpersonal, time management and communications skills.
• Strong leadership skills.
• Strong conflict resolution and independent decision-making skills.
• Expert project management ability.
• Strong influencing, negotiation and analytical skills.
• Working knowledge of PC based applications such as Excel, Access and Word.
• Knowledge of the principles of Utilization, Quality and Care Management.

Work Shift

Workday Day (United States of America)

Worker Sub Type

Temporary

Primary Location Address

901 Market Street, Philadelphia, Pennsylvania, United States of America