Major Functions (Duties and Responsibilities)

1. Develop and implement medical policy for utilization management activities and functions, including benefit manual statement, policies and procedures, and Utilization Management Subcommittee Guidelines. Provide training and consultation for both internal staff and medical personnel of the Plan regarding policy application.
2. Provide direction and control of current medical practices ensuring that medical personnel of the Plan follow medical protocols and rules of conduct.
3. Ensure assigned patients are provided healthcare services and necessary medical attention at all locations.
4. Collaborates with Contracting Department to ensure full and appropriate primary, specialty, and ancillary care network adequacy for Members.
5. Ensures that medical decisions are rendered by qualified medical personnel, unhindered by fiscal or administrative management. Provides clinical oversight and direction over credentialing process.
6. Ensures that medical care rendered by providers meets with applicable professional standards for acceptable medical care and quality.
7. Consults on written medical protocol for Plan physicians to ensure adherence to current standards and quality of medical care. Coordinates professional interactions among practitioners and lends assistance toward correcting any deviation from medical standards.
8. Interacts regularly with inpatient hospitalist groups, PCP & specialists to ensure appropriate medical care is provided and utilization standards are met.
9. Develops and manages a formal Utilization Management Program for the Plan and its Providers. This Program includes protocol, procedures, oversight, and training in the following areas:
a. Provider Selection
b. Credentialing
c. Peer Review Activities
d. Referral Management
e. Pre-admission authorization
f. Prospective, concurrent, and retrospective review
g. Utilization review reporting and evaluation
h. Case Management
i. Provider Incentive Programs
j. Chairperson/ Co-Chair of the HEDIS Improvement Committee, Quality Management Committee, Quality Improvement Committee, Credentialing Committee, Grievance Trend Committee
k. Participates on the Pharmacy and Therapeutics Subcommittee
l. NCQA Accreditation.
10. Act as a liaison to Provider Relations as a link between IEHP and individual physician, IPA’s, medical groups, and hospitals.
11. Adjudicate medically related grievances and appeals that flow through the Member grievance and appeals process.
12. Review State mandated benefits to ensure IEHP is in full compliance through its Providers.
13. Assist Compliance on sanctioned and excluded Provider management. Responsibilities include oversight of safe transitions of care for Members and communication with regulatory agencies and impacted departments (e.g., Pharmacy, Claims, Care Management, Utilization Management, etc.).
14. Provide physician level guidance on organizational improvement initiatives, including LEAN activities and Process Improvement Team projects.

Supervisory Responsibilities

Leader: Administers Hires, Terminations, and Performance Reviews

Experience Qualifications

Five (5) years or more of post-residency experience in a recognized medical specialty, which must have included at least one (1) year of medical leadership experience.

For Covered California Candidates - Three (3) years of experience with Covered California or other commercial Healthcare products.

Preferred Experience

Medical Director for an IPA, medical group, or HMO highly desirable. Utilization management experience is a plus. Primary Care Physician in internal medicine, family practice or pediatrics preferred.

Education Qualifications

Doctorate of Medicine from an accredited institution required.

Professional Certification

Certification by one (1) of the American Specialty Boards.

Professional Licenses

Possession of an active, unrestricted, and unencumbered Physician’s and Surgeon’s license issued by the State of California Medical Board required.

(A physician certified in a state other than California may be employed prior to receipt of a California license provided that an application for a California physician and surgeon’s license is filed in the state of California prior to date of appointment.)

Primary Care Physician in internal medicine, family practice or pediatrics preferred.

Knowledge Requirement

Strong knowledge of medical and CMS regulations. Administrative practices and procedures (including but not limited to quality assessment and improvement, utilization review, peer review, credentialing and risk management; rules, regulations, policies, and standards related to managed care; principles of effective supervision and organization; methods, techniques, practices, principles, and literature in the broad field of medical sciences; and overview of the highly specialized techniques, procedures, and equipment used in the medical or surgical specialties.)

A reasonable salary expectation is between $240,676.80 and $330,928.00, based upon experience and internal equity.

Job Type: Full-time

Pay: $240,676.80 - $330,928.00 per year

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Paid time off
• Tuition reimbursement
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday

Supplemental pay types:

• Bonus pay

Ability to commute/relocate:

• Rancho Cucamonga, CA 91730: Reliably commute or planning to relocate before starting work (Required)

License/Certification:

• Medical License (Preferred)

Willingness to travel:

• 25% (Preferred)

Work Location: Hybrid remote in Rancho Cucamonga, CA 91730

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