Medical Director, Prior Authorization & Care Optimization

360X Staffing; Chino (CA); Presencial; USD 180.000 - 240.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Health insurance

Descripción de la vacante

360X Staffing seeks an experienced Medical Director of Prior Authorization to lead medical necessity reviews for our provider network across Pomona, Chino, and surrounding communities in California. This physician leader will guide utilization management, care coordination, and provider relationships to ensure appropriate, high-quality care.

The role requires a California-licensed MD with at least five years in clinical practice and prior authorization experience; board certification preferred.

Formación

• Medical knowledge and clinical decision-making.

Responsabilidades

• Review pre-service authorization requests using evidence-based clinical guidelines.
• Make determinations regarding approvals, denials, modifications, and redirection of care.
• Collaborate with physicians, nurses, and clinical coordinators to provide high-quality care.
• Identify high-risk patients and coordinate with internal teams to improve outcomes.
• Provide cross-coverage and secondary/tertiary review for additional locations when needed.
• Conduct retrospective inpatient and outpatient claims reviews.
• Partner with network management to build relationships with physicians.
• Serve as a clinical resource regarding utilization management and documentation requirements.
• Participate in grievance, appeal, quality improvement, and peer-review activities.

Descripción del empleo

360X Staffing seeks an experienced Medical Director of Prior Authorization to lead medical necessity reviews for our provider network across Pomona, Chino, and surrounding communities in California. This physician leader will guide utilization management, care coordination, and provider relationships to ensure appropriate, high-quality care.

The role requires a California-licensed MD with at least five years in clinical practice and prior authorization experience; board certification preferred.