Regional Medical Director - NAMM/PrimeCare California (Ontario, Corona) - Full-time / Part-time

North American Medical Management, California, Inc (NAMM California) partnered with OptumHealth in 2012. NAMM/PrimeCare California and OptumHealth share a common goal of bringing patients, physicians, hospitals and payers closer together in the mission to increase the quality, efficiency and affordability of care. NAMM California is a part of the family of companies that make UnitedHealth Group one of the leaders across most major segments of the US health care system. NAMM California develops and manages provider networks, offering a full range of services to assist physicians and other providers in supporting patient care coordination and their managed care business operations. For over 18 years, NAMM California has been an innovator in health care with a track record for quality, financial stability, extraordinary services and integrated medical management programs. NAMM California is well positioned to continually invest in its infrastructure and systems for the benefit of its provider clients and to accommodate the impending changes that will come forth from healthcare reform.

The NAMM California provider clients represent a network of almost 600 primary care physicians and over 3,000 specialists and work with the premier hospitals in their respective markets.

The Medical Director provides physician support to Clinical Coverage Review (CCR) operations, the organization responsible for the initial clinical review of service requests for UnitedHealth Care (UHC). The Medical Director collaborates with CCR leadership and staff to establish, implement, support and maintain clinical and operational processes related to benefit coverage determinations. They will work to build and cement relationships and continuously educate on regulatory guidelines within managed care. Many of the Medical Director's activities will focus on the application of clinical knowledge in various utilization management activities and detail around pre-service benefit and coverage determination or medical necessity (according to the benefit package), and on communication regarding this process with both network and non-network physicians, as well as other UnitedHealth Care departments.

Primary Responsibilities:

• Conduct coverage review based on individual member plan documents, and national and proprietary coverage review guidelines, render coverage determinations, and discuss with requesting providers as needed in peer-to-peer telephone calls


• Use clinical knowledge in the application and interpretation of UHC medical policy and benefit document language in the process of clinical coverage review for UnitedHealth Care


• Manage healthcare costs by actively overseeing daily inpatient and outpatient services by analyzing data and driving metric


• Conduct daily clinical review and evaluation of all service requests collaboratively with Clinical Coverage Review staff


• Provide support for CCR nurses and non clinical staff in multiple sites in a manner conducive to teamwork


• Communicate and collaborate with network and non-network providers in pursuit of accurate and timely benefit determinations for plan participants; educates providers on benefit plans and UHC medical policy


• Communicate with and assist Medical Directors outside CCR regarding coverage and other pertinent issues


• Communicate and collaborate with other departments such as the Inpatient Concurrent -Review team regarding coverage and other issues


• Is available and accessible to the CCR staff throughout the day to respond to inquiries. Serve as a clinical resource, coach and leader within CCR


• Access clinical specialty panel to assist or obtain assistance in complex or difficult cases


• Document clinical review findings, actions and outcomes in accordance with CCR policies, and regulatory and accreditation requirements


• Actively participate as a key member of the CCR team in regular meetings and projects focused on communication, feedback, problem solving, process improvement, staff training and evaluation and sharing of program results


• Actively participate in identifying and resolving problems and collaborates in process improvements that may be outside own team


• Provide clinical and strategic leadership when participating on national committees and task forces focused on achieving Clinical Coverage Review goals
  
  

Required Qualifications:

• Active, unrestricted physician license


• Current board certification in ABMS or AOA


• Board certified in internal medicine or Emergency medicine specialty


• 5+ years of clinical practice experience after completing residency training


• 2+ years' hands-on experience in utilization and coverage review in a health plan or IPA with senior and commercial membership


• Demonstrated, strong relationship buildling/team building skills and abilities


• Excellent professional presentation skills for both clinical and non-clinical audiences


• Substantial experience in using electronic clinical systems in the payer setting


• Experience with managed care industry


• Strong belief in EBM (Evidence Based Medicine), and familiarity with current medical issues and practices


• High level of proficiency with MS Word, Outlook, and Excel


• Data analysis and interpretation experience and skills

Preferred Qualifications:

• HCC coding


• Supervisory skills, including clinical mentoring and coaching expertise


• Project management background


• Creative problem solving skills

Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make the health system work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.SM

Diversity creates a healthier atmosphere: All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment

Job Keywords: Medical Director, Clinical, Doctor, Managed Care, Physician, Clinician, Irvine, Ontario, California, CA