Medical Director, Prior Auth

Regal-Medical-Grou; California; Presencial; USD 250 000 - 350 000; Tempo integral

Vantagens oferecidas por esta oferta de emprego

Health insurance

Vision insurance

FSA

Life insurance

EAP

CME stipend

Resumo da oferta

Regal Medical Group, Lakeside Community Healthcare & Affiliated Doctors of Orange County seeks an experienced Medical Director of Prior Authorization to oversee medical necessity reviews across Pomona, Chino, San Gabriel Valley, and surrounding areas.

The role requires five years of clinical practice with managed-care exposure, strong communication, and collaboration with physicians and staff to ensure access to appropriate care while containing costs.

Qualificações

• MD required with clinical experience.
• Board certification preferred; board eligible acceptable.
• Minimum five years of prior clinical experience; managed-care experience preferred.
• Demonstrated ability to interpret and apply clinical guidelines and organizational policies.
• Excellent communication and teamwork across providers and staff.

Responsabilidades

• Prior authorization & medical management reviews for appropriate medical necessity.
• Coordinate with medical directors, nurses, and reviewers to improve care quality and cost-effectiveness.
• Review requests for medical necessity using evidence-based guidelines and policies.
• Identify high-risk patients and coordinate with care teams to reduce unnecessary utilization.
• Engage with primary care physicians and specialists to discuss best practices in patient care and referrals.
• Perform cross-coverage, secondary/tertiary reviews, and director decisions as needed.
• Conduct retroactive claims reviews for outpatient and inpatient care.

Conhecimentos

Clinical leadership

Communication skills

Analytical review

Time management

Policy interpretation

Team collaboration

Medical documentation

Formação académica

MD (Doctor of Medicine)

Board certification preferred

Ferramentas

MS Office

Descrição da oferta de emprego

Regal Medical Group, Lakeside Community Healthcare & Affiliated Doctors of Orange County are seeking an experienced Medical Director, Prior Authorization to support our network in Pomona, Chino, San Gabriel Valley and surrounding communities. This physician leader will ensure that patients receive the right care at the right time and in the right setting through high-quality medical necessity review, care coordination, and strong provider relationships.

Role summary

The Medical Director is responsible for actively participating in the review process of pre-service requests for services and applying appropriate clinical guidelines to determine medical necessity. The role includes making recommendations for approvals, denials, modifications, or redirections, while collaborating closely with other physician reviewers, nurses, and Medical Directors to deliver excellent, cost-effective care aligned with medical management and referral processing guidelines. The ideal candidate is detail-oriented and skilled at evaluating complex clinical information, communicating clearly with members and providers, and supporting internal teams.

Key responsibilities

Prior authorization & medical management

• 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.
• Participate, as part of a team of medical directors, nurses, and coordinators, in the pre-service medical necessity review of patient care.
• Review prior authorization requests for medical necessity using appropriate, evidence-based clinical guidelines and policies.
• Identify high-risk patients and help coordinate care with the Employer’s high-risk team to improve outcomes and reduce avoidable utilization.
• Meet periodically with primary care physicians, specialists, and provider groups to review best practices for patient care and referral quality.
• Perform prior authorization functions for various Employer campuses, including cross coverage, secondary/tertiary review, and medical director decision-making when needed.
• Conduct retroactive claims review for outpatient and inpatient care, as needed.

Provider relations

• Work with the Employer’s network management team to establish and maintain strong provider relations within the IPA.
• Serve as a direct resource to IPA providers on utilization management issues and other aspects of patient care, including authorization criteria and documentation expectations.

Quality, grievance, and appeals

• Understand the Employer and its affiliates’ internal Quality, Grievance & Appeals (Q/G&A) programs and participate in review and response to grievances, appeals, and peer review cases.
• Attend and contribute to meetings to review, develop, and continually improve internal quality improvement and peer review processes and programs.
• Provide verbal counseling to IPA providers following G&A determinations, collaborating on corrective action plans and follow-up activities.

Compensation

• Base salary range at commencement of employment: $250,000 – $350,000 per year depending on experience.
• Actual base pay may vary based on market location, job-related knowledge, licensure, skills, and experience.
• The total compensation package may also include:
• Sign-on bonus.
• Discretionary awards.

This is an at-will position, and the Company reserves the right to modify base salary and any other discretionary payment or compensation program at any time, including for reasons related to individual performance, Company performance, department/team performance, and market factors.

Who We Are

As one of the fastest-growing Independent Physician Associations in Southern California, Regal Medical Group, Lakeside Community Healthcare & Affiliated Doctors of Orange County offer a fast-paced, exciting, welcoming, and supportive work environment. Opportunities abound for enterprising, capable, and focused individuals, and we promote teamwork, nurture learning, and encourage advancement for all employees. We believe your success is our success and are committed to helping you excel.

We are dedicated to employee satisfaction and to supporting the health and wellness of our members by providing employees with options and resources to build security and maintain work–life balance. Our comprehensive benefits package includes many employer-paid options:

Health and wellness

• Employer-paid comprehensive medical, pharmacy, and dental coverage for employees.
• Vision insurance.
• 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.

Additional benefits

• Vacation time, sick days, and paid holidays.
• Company celebrations and Employee Referral Bonus program.
• Tuition reimbursement and License Renewal CEU Cost Reimbursement Program.
• CME stipend and paid CME time.
• Malpractice insurance coverage.
• Business-casual working environment.
• Mileage

Employer will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of the LA City Fair Chance Initiative for Hiring Ordinance.

Requirements

Education and experience requirements

• Doctor of Medicine (MD) degree required.
• Specialty training and/or managed care experience preferred.
• Board certification preferred; board eligible acceptable.
• Minimum of five years of prior clinical experience required, with at least two years of managed-care or health-plan experience** preferred.
• Demonstrated strong clinical fund of knowledge and familiarity with clinical research principles.
• Ability to interpret and apply clinical guidelines and organizational policies in day-to-day decision-making.

Skills and competencies

• Strong proficiency in MS Office programs (Word, Excel, Outlook, Access, PowerPoint) and ability to conduct research over the internet.
• Excellent communication skills, both verbal and written, with the ability to explain complex clinical and utilization concepts to diverse audiences.
• Ability to type at least 50 words per minute with accuracy.
• Strong organizational skills and ability to work effectively in a multi-task, high-stress environment.
• Proven ability to handle multiple projects simultaneously, reset priorities day-to-day to meet deadlines, and seek assistance appropriately when priorities conflict.
• High personal ethics; self-motivated, self-guided, and driven to improve patient care and operational performance.
• Ability to work with all levels of management and develop positive working relationships with medical directors and company department heads.
• Ability to deal responsibly with confidential matters and adhere to all regulatory and organizational standards.
• Must be able to attend on-site department meetings and trainings when needed.