UM Medical Director / Physician Advisor

Location: Orange, California US

Notice

This position is no longer open.

Job Number: 1636

Workplace Type:

Position Title: Director, Utilization Management

External Description:

Alignment Healthcare (AHC) is seeking a utilization management (UM) medical director / physician advisor to work with UM licensed staff, regional medical officers and extensivists to develop and implement methods to optimize use of institutional and outpatient services for all patients while also ensuring the quality of care provided. As the UM medical director / physician advisor, you will access our web-based portal, medical director / physician advisor to complete clinical reviews for medical necessity, treatment appropriateness, and compliance. The UM medical director / physician advisor reports to the Chief Health Officer.

General Duties and Responsibilities

(May include but are not limited to)

  • Second level reviews in compliance with Medicare / CMS: NCD, LCD and Milliman guidelines for inpatient, outpatient, skilled facilities level of care, and pharmacy.
  • Provide appropriate level of care classifications as well as continued stay reviews in compliance with CMS and Milliman guidelines.
  • Act as a liaison between the medical staff, utilization review and third-party payers to effectively promote the appropriate levels of medical care.
  • Review the entire claim denial process, including pending claims, appeals and grievances.
  • Serve as a physician member of the utilization review team.
  • Ensure appropriate service utilization by monitoring over- and under-utilization
  • Work with interdisciplinary team to develop AHC utilization management protocols, including auto-approvals and market specific protocols.
  • Develop training material and assisting UM manager to conduct physicians' annual interrater reliability testing
  • Serve as a subject matter expert (CME) to regional medical officers and / or extensivists during concurrent reviews.
  • Serve as a chairperson / member for medical quality committee and provide clinical oversight of quality outcomes.
  • Collaborates closely and assist quality director.
  • Work with provider relation, network management and local regional medical officers to ensure community physician education on UM processes and regulations
  • Assist the organization to challenge physician practices to achieve the organization's clinical outcomes and collaborates closely and assists quality director.

Supervisory Responsibilities

UM clinical staff oversight

Minimum Requirements

  1. Minimum Experience:
    1. Minimum 3 years’ experience in hospital-wide or skilled nursing facility position involving clinical care, quality management, utilization and case management, or medical staff governance required. Experience as a physician advisor a plus
  1. Education / Licensure:
    1. Completion of medical school and specialty residency (preferably in internal medicine) required. Sub-specialty or other post-residency fellowship (preferred) and board certification required. Applicants must have current, non-restricted licensure as required for clinical practice in the State or US territory in which medical decisions are being made.
  1. Other:
    1. Able to build rapport with medical staff and management leadership to obtain necessary approvals of new strategies for utilization management.
    2. Knowledge of current medical literature, research methodology, healthcare delivery systems, healthcare financial / reimbursement issues, and medical staff organizations.
    3. Dedication to the delivery of high-quality, cost-effective, efficient patient care services
    4. Excellent communication skills
    5. Must have great attention to detail as well as taking pride in being a good team member and communicate effectively with medical staff.
    6. Mon- Fri 8- 5PM with some weekend requirements.
    7. Flexible schedule

Essential Physical Functions

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  1. While performing the duties of this job, the employee is regularly required to talk or hear.
  2. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
  3. The employee frequently lifts and / or moves up to 10 pounds.
  4. Specific vision abilities required by this job include close vision and the ability to adjust focus.

FLSA Status: Exempt

City: Orange

State: California

Location City: Orange

Location State: California

Community / Marketing Title: UM Medical Director / Physician Advisor

Company Profile:

By leveraging our world-class technology platform, innovative care delivery models, deep physician partnerships and our serving heart culture, Alignment Health is revolutionizing health care for seniors! From member experience professionals and clinicians, to data scientists and operations leaders, we have built a talented and passionate team that is deeply committed to our mission of transforming health care for the seniors we serve. Ready to join us?

At Alignment, delivering exceptional care to seniors starts with ensuring an exceptional experience for our over 1,300 employees. At the center of our employee experience is a culture where employees at all levels and across all teams are encouraged to share their unique ideas and perspectives. After all, when you can bring your authentic self to work, whether that’s in a clinical setting, our corporate office or a home office, creativity and innovation flourish! Another important part of the Alignment culture is a belief in continuous learning and growth. As a result, in this fast-growing company, you will find ample support to grow your skills and your career – with us.

EEO Employer Verbiage:

 

Please note: All clinical positions are contingent upon successful engagement with Alignment Health’s COVID-19 Vaccination program (fully vaccinated with documented proof or approved exception/deferral).

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email [email protected].