Remote Medical Director – Utilization & Quality

Health Plan of San Joaquin/Mountain Valley Health Plan; French Camp (CA); Remote; USD 180,000 - 240,000; Full time

Job summary

Health Plan of San Joaquin in California is seeking a Medical Director consultant to provide clinical oversight of utilization, quality, pharmacy, credentialing, and health equity. This remote position requires residence in California and aims to deliver quality, cost-effective care while meeting regulatory standards.

Under limited supervision, you will lead medical management and perform reviews for authorizations and appeals, guide grievances and quality improvements, and participate in

Qualifications

• MD degree from an accredited medical school.
• Satisfactory completion of an ACGME accredited residency program.
• Board Certification in a chosen specialty.
• A Master’s Degree in Public Health may substitute for two years of clinical experience.

Responsibilities

• Provide clinical oversight of utilization management, quality, pharmacy, credentialing and health equity initiatives.
• Collaborate with Deputy CMO to identify service issues and develop action plans.
• Identify and analyze care and quality trends; implement approved changes.
• Provide clinical guidance for complex administrative cases.
• Conduct reviews for prior, concurrent, and retro authorizations and appeals per medical criteria.
• Review grievances and quality of care issues for Medi‑Cal and DSNP members; drive improvements.
• Offer expertise for activities to improve quality and health equity metrics.
• Maintain relationships with providers and stakeholders to support contracting and organizational goals.
• Collaborate to ensure medical compliance with regulatory and accreditation requirements.
• Serve on committees and represent HPSJ in the community.

Skills

Clinical leadership

Utilization management

Quality improvement

Credentialing

Health equity

Grievances handling

Data analysis

Communication skills

Interpersonal skills

Presentation skills

Collaboration

Budgeting

Strategic thinking

Problem solving

Project management

Organization savvy

English proficiency

Education

MD degree

Residency (ACGME)

Board certification

MPH degree (optional substitution)

Job description

Health Plan of San Joaquin in California is seeking a Medical Director consultant to provide clinical oversight of utilization, quality, pharmacy, credentialing, and health equity. This remote position requires residence in California and aims to deliver quality, cost-effective care while meeting regulatory standards.

Under limited supervision, you will lead medical management and perform reviews for authorizations and appeals, guide grievances and quality improvements, and participate in