Medical Director

Medical Director (Part-Time) Care Management California, United States Because health is personal. That's why Personify Health created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. We serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes. Together, our team is on a mission to empower people to lead healthier lives. ESSENTIAL DUTIES and RESPONSIBILITIES: The Medical Director relies on their medical background to review claims for medical necessity for prior authorization, continued stay review and post service. The Medical Director can read, interpret, and apply medical policy, guidelines, and research to utilization review. The Medical Director has authority for issuing adverse determinations while performing medical necessity evaluation. Has discussions with external physicians by phone to gather additional clinical information or discuss determinations regularly, and in some instances, these may require conflict resolution skills. Some roles include an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within their scope. Keep the team informed of clinical updates through educational opportunities by developing educational materials for staff. Work with the VP of Care management to establish work procedures and processes that support company and departmental standards, procedures, and strategic directives. Excellent verbal and written communication skills. Evidence of analytic and interpretation skills, with prior experience participating in teams focusing on quality management, utilization management, case management, discharge planning and/or home health or post-acute services (such as inpatient rehabilitation). Knowledge of the managed care industry as it relates to commercial business. Oversee the negotiation and implementation of cost management strategies to affect quality outcomes and reflect this data in monthly case management reviews as it relates to clinical aspects in case management and utilization review rounds. Exercises independence in meeting departmental expectations and meets compliance timelines. Ability to meet productivity, quality, and turnaround times daily. Ability to pass external audits to include URAC and NCQA. Maintain HIPPA compliance per company's policy and procedures. Maintain confidentiality and minimum requirement rules. Complete all required yearly training per company's expected period.