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Location

Long Beach, CA | United States

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Job description

Position Summary: In a brief statement; explain the basic purpose of the position.
This position is responsible for MemorialCare Medical Foundation utilization management processes and performance with activities including ambulatory utilization management and case management in a regulatorily compliant manner along with identifying potential areas of improved clinical care that may result in better clinical outcomes and appropriate utilization. These activities will require this position to act as a liaison with Medical Management, external and internal providers and health plan partners. The Assistant UM Medical Director will also support regulatory processes such as UM denial appeals in collaboration with the Quality team.

Principal Duties and Responsibilities: Briefly describe the major responsibilities and functions of this position.


1. Participate in MCMG ambulatory referral process in collaboration with the MCMF UM Medical Director and Directors of Medical Management and Ambulatory Care Managers.


2. Review all non-routine referral requests for MCMG including letter of agreement requests, tertiary referral requests, and complex cases.


3. Support Ambulatory Care Managers, Referral Coordinators and Utilization Management Physicians in referral decision-making process.


4. Support regulatory compliance function of Medical Management in the referral review process including review of referral denials, appeals and overturns.


5. Work in collaboration with Medical Management team on health plan and CMS audit process.


6. Provide support for the Patient Care Committees and the Facility Medical Directors/Utilization Management Physicians in MCMG offices regarding utilization management process and consultations of individual cases and referral decisions as well as preferred specialty network for managed care and ACO populations. Communicate referral request decisions to the Utilization Management Physicians and providers within and outside of MCMG.


7. Assist in the identification of factors that impact medical expenses for all risk products. Work with MCMF UM Medical Director to control medical expenses for MCMG and reduce in-patient admissions.


8. Provide support for MCMG case management functions Participate in Virtual Case Conference in support of high risk members and complex case management team.


9. In coordination with the MCMF UM Medical Director and Senior Medical Director, the Assistant UM Medical Director may participate in on-going education to all MCMG providers on pertinent UM topics including trends, network selection/changes, regulatory changes, or other actionable information that will improve patient outcomes and systemic efficiencies.5 or more years of clinical practice required

Board certification in specialty required

In-patient experience preferred

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Salary