Required Qualifications: Active CA MD License + 5 years experience in UM
City/State:Los Angeles, CA
*Qualified candidates may be eligible for a higher salary than advertised*
Employer: One of the most successful IPAs in California has been experiencing rapid growth, and is seeking a talented Director of Utilization Review. The role is unique in that they are open to candidates that are either a current Director, and or also an inexperienced, but talented Physician. The IPA offers significant career opportunities beyond this position, and also prioritizes work-life balance, with a Monday-Friday 8am-5pm schedule.
Overview: This position is responsible for the IPA’s Utilization Review functions. Additionally, this position must work collaboratively with the Medical Services and Managed Care Departments while interacting with physicians, health plan staff, members of Clinical Leadership Council, and health plan members.
Work in collaboration with Medical Directors of Medical Management, Quality, Innovation and Medical Informatics in all aspects of their jobs.
Lead team of 3-8 employees, including RNs, LVNs, and Referral Coordinators.
Review referrals from sources within IPA, and collaborate with referral nurses.
Monitor utilization trends and communicate program outcomes to IPA leadership and physicians.
Promote the appropriate utilization of programs to manage complex and/or catastrophic cases and to promote positive health outcomes through disease management interventions.
Provides feedback and education to IPA physicians regarding UM Initiatives.
Assess the adequacy of information being provided by the IPA to the IPA's providers and assist in development of any new or revised materials
Assist staff from a clinical perspective in development of fee schedules or in payment methodologies.
Develop educational programs for the physician network regarding Utilization Review
Skills and Abilities:
Exceptional leadership, critical thinking, deductive reasoning and decision making skills in managing resources, monitoring the cost effectiveness and quality of services to participants.
Strong knowledge of HMO, Commercial Health Plans, and Medi-Cal
Ability to work as a team member and participate in the assessment and evaluation process of potential and existing referrals.
Ability to supervise, evaluate, coach, and develop providers.
Qualifications: A valid, unrestricted license to practice medicine in the State of California and be Board certification in the chosen specialty required.· 3+ years of clinical practice in direct patient care· Past UM experience at the IPA or Health Plan level is highly desirable.· Electronic Medical records experience preferred.