Overview
To oversee the appropriateness and quality of care delivered through Partnership HealthPlan of California and for the cost-effective utilization of services.
Responsibilities
- Performs Treatment Authorization Request (TAR) review and appeals to determine medical necessity, appropriateness of services, interprets benefits and limitations, and reviews claims, which are questionable in dollar amount or volume or scope of services. Assures that care is at all times at an acceptable level of quality.
- Confers with and counsels participating physicians who have questionable patterns of utilization.
- Coordinates with Utilization Management department managers and directors to provide daily support and appropriate direction to staff on issues pertaining to UM.
- Assists in developing and revising policies to support utilization management activities, including criteria and guidelines for appropriate use of services, clinical practice guidelines and treatment guidelines.
- Serves on Quality/Utilization Advisory Committee, Pharmacy & Therapeutics Committee, Credentials Committee and Internal Quality Improvement Committee as requested by the Chief Medical Officer. May work with community provider committees and Advisory boards on medical issues and policies.
- Reviews potential quality issues and determines their appropriateness for review by the Peer Review Committee.
- Advises the Grievances and Appeals Department on preparing for, and testifying, in State Fair Hearings.
- Engagement of the Partnership provider network to improve quality of care and member experience.
- Performs Pharmacy Authorization review and appeals to determine medical necessity and appropriateness of prescribed medications.
- Acts as liaison to local Medical community.
- Other activities related to region assignment, as assigned.
- Other duties as assigned.
Qualifications
Education and Experience
Medical Doctor or Doctor of Osteopathy, plus completion of a residency program. Minimum of 5 years post-residency clinical experience.
Special Skills, Licenses and Certifications
California Medical License. Board Certification in an American Board of Medical Specialist Specialty. Understanding of outpatient clinical practice and hospital medicine. Valid California driver’s license and proof of current automobile insurance compliant with Partnership policy are required to operate a vehicle and travel for company business.
Performance Based Competencies
Advanced computer skills, including proficiency in multiple software applications including Microsoft Office. Ability to present data in a local, concise manner. Ability to analyze complex medical issues.
Work Environment And Physical Demands
More than 50% of work time is spent in front of a computer monitor. Must be able to work in a fast-paced environment and maintain courtesy and composure.
All HealthPlan employees are expected to:
- Provide the highest possible level of service to clients;
- Promote teamwork and cooperative effort among employees;
- Maintain safe practices; and
- Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.
HIRING RANGE
$260,773.07 - $352,041.65
IMPORTANT DISCLAIMER NOTICE
The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.
