Medical Director, Utilization Management Job at L.A. Care Health Plan (Los Angeles)

Medical Director, Utilization Management

L.A. Care Health Plan

Location:
United States , Los Angeles

Category:
Health and Beauty

Contract Type:
Not provided

Salary:

206311.00 - 350729.00 USD / Year

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Job Description:

The Medical Director, Utilization Management provides clinical oversight of authorization decision making and processing, pre and post payment claims review activities, payment integrity clinical validation and program integrity functions. This position requires evaluation and insight for both medical and behavioral health cases. In this position, the Medical Director supports the development of and ensures the application of clinical policies are consistent with evidence-based medicine and regulatory requirements.

Job Responsibility:

Provides clinical oversight of authorization decision making and processing, pre and post payment claims review activities, payment integrity clinical validation and program integrity functions
Supports the development of and ensures the application of clinical policies are consistent with evidence-based medicine and regulatory requirements
Collaborates with internal teams to support timely consistent and defensible clinical decisions and promotion of appropriate high-value care
Reviews clinical documentation to validate coding accuracy and appropriateness and completion of billed services
Plays a critical role in the mitigation of Fraud, Waste and Abuse (FWA)
Requires proactive analysis of service level utilization data to identify trends, outliers and emerging risk areas and recommend corrective action
Works collaboratively with Health Services departments and key organizational stakeholders
Partners with executive leadership, clinical teams, and external stakeholders to improve outcomes, support regulatory compliance, and advance organizational goals
Provides physician leadership within the Health Services division
Applies clinical expertise and evidence-based criteria to behavioral health and medical/surgical services
Leads efforts to strengthen Payment Integrity by overseeing clinical validation of requested services
Analyzes utilization and claims data to identify trends, outliers, cost drivers, and opportunities
Identifies and mitigates Fraud, Waste, and Abuse (FWA) risks
Develops, approves, and updates medical policies, procedures, and standards of care
Oversees and reviews the delivery of patient care to ensure it meets quality standards and regulatory guidelines
Guides quality assurance and performance improvement (QAPI) programs and participates in quality review committees
Maintains and enforces compliance with all federal and state laws, accreditation standards, and other regulatory requirements
Assists in the preparation and monitoring of departmental budgets
Performs other duties as assigned

Requirements:

Doctor of Medicine (M.D.)
At least 8 years of experience in medical management, managed care and quality management
Experience in Payment Integrity
Experience in maintaining liaison with Federal, State, and local bodies and medical organizations
Experience in performance management and possession of strong analytic ability
Extensive post-medical degree experience in clinical practice
Significant experience in a clinical development, medical affairs, or management role within the biotech, pharmaceutical, or healthcare industry
Proven experience in a physician leadership role, including managing teams
Ability to provide leadership to physicians, nurses, and other health care professionals
Excellent written and verbal communication skills
Strong leadership, consensus-building, and stakeholder engagement skills
Commitment to evidence-based practice, continuous quality improvement, regulatory compliance, and health equity
Demonstrated ability for teamwork and collaborative problem-solving
Commitment to patient-centered, value-based care
Strong leadership presence with the ability to lead, mentor, and motivate a team
Exceptional presentation skills
Ability to think strategically and take a broad, business-oriented perspective
Strong analytical and problem-solving skills
Ability to work in a fast-paced, dynamic, and often ambiguous environment
Board Certified, preferably in Internal Medicine, Family Medicine, Emergency Medicine or Psychiatry
Clinical License to practice or an Administrative License to review Utilization Management cases
Active, current and unrestricted California License

Nice to have:

Experience with Medicaid managed care and/or governmental programs for underserved, safety net populations including women, children, person with disabilities, seniors, and those of varied ethnic and cultural backgrounds
Certification as a Certified Medical Director (CMD)

What we offer:

Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)

Additional Information:

Job Posted:
March 22, 2026

Employment Type:

Fulltime

L.A. Care Health Plan - All Job Offers

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