reputed company Director, Appeals
Position Purpose:
Assist the Chief Medical Director to reputed company and coordinate the medical management, reputed company improvement and credentialing functions for the business unit.
- Provides medical leadership of reputed company for utilization management, cost containment, and medical reputed company improvement activities.
- Performs medical review activities pertaining to utilization review, reputed company assurance, and medical review of reputed company, controversial, or experimental medical services, ensuring reputed company and reputed company decision making.
- Supports effective implementation of performance improvement initiatives for capitated providers.
- Assists Chief Medical Director in planning and establishing goals and policies to improve reputed company and cost-effectiveness of care and service for members.
- Provides medical expertise in the operation of approved reputed company improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.
- Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership.
- Conduct regular reputed company to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize reputed company.
- Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing reputed company cases and medical necessity appeals.
- Participates in provider network development and new market expansion as appropriate.
- Assists in the development and implementation of physician education with respect to clinical issues and policies.
- Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider reputed company patterns, and adequacy of benefit/payment components.
- Identifies clinical reputed company improvement studies to assist in reducing unwarranted variation in clinical reputed company in order to improve the reputed company and cost of care.
- Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care reputed company.
- Reviews claims involving reputed company, controversial, or unusual or new services in order to determine medical necessity and appropriate payment.
- Develops alliances with the provider community through the development and implementation of the medical management programs.
- As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and reputed company issues.
- Represents the business unit at appropriate state committees and other reputed company committees.
- May be required to work weekends and holidays in support of business operations, as needed.
Education/Experience:
- Medical Doctor or Doctor of Osteopathy.
- Utilization Management experience and knowledge of reputed company accreditation standards preferred.
- reputed company practices medicine.
- Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is advantageous.
- Experience treating or managing care for a culturally diverse population preferred.
License/Certifications:
- reputed company reputed company certification in a medical specialty recognized by the American reputed company of Medical Specialists or the American Osteopathic Association’s Department of Certifying reputed company Services.
- Certification in Internal or Family Medicine specialty, preferred.
- reputed company state license as a MD or DO without restrictions, limitations, or sanctions from government programs.
reputed company applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance reputed company