About Us:

Santa Clara Family Health Plan (SCFHP) is a local, community-based health plan dedicated to improving the health and well-being of the residents of Santa Clara County. Working in partnership with providers and community organizations, we serve our neighbors through our Medi-Cal and Cal MediConnect (Medicare-Medicaid Plan) health insurance plans.

About the role:

Responsible for the appropriateness and quality of care delivered through SCFHP and for cost-effective utilization of services. Responsible for Medi-Cal, and Medicare lines of business.

Day to Day:

• Performs treatment authorization review to determine medical necessity, appropriateness of services, and interpret benefits and limitations.
• Reviews that care is consistent with the Plan’s standards of quality.
• Participates in concurrent review activities of inpatient and long term care plans.
• Reviews claims that are unusual in cost, volume or scope of services.
• Acts as liaison between SFCHP and community providers, conferring and meeting as required.
• Coordinates with Directors of Medical Management and Quality Improvement to provide daily support and appropriate direction to staff on issues pertaining to UM and QI.
• Prepares and acts as a subject matter expert for all external and internal audits with regulators including: DMHC, CMS, DHCS, NCQA.
• Assists in developing and revising policies to support utilization management activities, including criteria and guidelines for the appropriate use of services clinical practice guidelines, and treatment guidelines.
• May serve on Quality Improvement Committee, Utilization Management Committee, Pharmacy and Therapeutics Committee, Credentialing Committee as requested by the Chief Medical Officer.
• The Medical Director 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.
• Performs Pharmacy Prior Authorization review in support of the Pharmacy Director
• Participates in the Grievance and Appeal process as required, including performing second-level reviews of previous denials.
• Ensure the privacy and security of PHI (Protected Health Information) as outlined in SCFHP policies and procedures relating to HIPAA compliance.

About You:

• Current unrestricted license to practice medicine in the State of California.
• Board Certified in a recognized medical practice specialty.
• Five years of post-residency experience in a recognized medical specialty.
• One year utilization management experience for an Independent Practice Association, medical group or HMO.
• Working knowledge of HEDIS, NCQA standards, Medi-Cal Managed and Medicare.
• Experience in medical review systems.

Please review the full job description and apply on our Career’s page: https://phf.tbe.taleo.net/phf04/ats/careers/v2/viewRequisition?org=SANTCLAR2&cws=38&rid=2834

Job Type: Full-time

Pay: $227,539.00 - $295,801.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Retirement plan
• Tuition reimbursement
• Vision insurance

Schedule:

• Monday to Friday

Ability to commute/relocate:

• San Jose, CA 95119: Reliably commute or planning to relocate before starting work (Preferred)

Application Question(s):

• Do you have an unrestricted License to practice Medicine in the state of California?
• Do you have a working knowledge of HEDIS, NCQA standards, Medi-Cal Managed, and Medicare? Experience in medical review systems?
• Do you have five years of post-residency experience in a recognized medical specialty?
• Do you have one-year utilization management experience for an Independent Practice Association, medical group, or HMO?

Work Location: One location

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