Job Description
We are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care. We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives. Through collaboration, we strive to provide all of our patients and medical group members with the quality, affordable healthcare they need and deserve.
The Medical Director of Utilization Management provides medical leadership and has responsibility for the PMS Utilization Management Department. Responsibilities include facilitation of evidence-based and cost-effective professional and institutional services to our membership through oversight of the day-to-day operations. Mentoring and assisting in the training of clinical and non-clinical leaders to ensure compliance with legal requirements. Chairs and/or participates in various committees to support performance improvement, improve utilization and quality of medical care, and the physician and patient experience - including, but not limited to oversight of peer review and risk management. Engages physicians to promote relationships and alignment with organizational goals.
Job Responsibilities/Duties
- Provides physician oversight of the Utilization Management and Prior Authorization process to ensure the delivery of cost-effective, high quality, and appropriate medical care as needed
- Adherence to Prospect’s denial process and compliance with industry standards and denial ratios
- Works closely with UM team members in meeting timely turnaround on referrals
- Collaborates with team members in the development, implementation, management, monitoring, and evaluation of the effectiveness of UM processes
- Physician education and manages relationships with health plans
- Works proactively and collaboratively across the organization to ensure overall business objectives are met and supported.
- Attends various meetings and participates on committees as appropriate contributing ideas for improving efficiency, productivity, and member satisfaction
- Other job duties as assigned
Qualifications
Minimum Education: None.
Minimum Experience: Five (5) years of clinical care experience. Minimum of three (3) years of utilization management. Strong clinical acumens. Some experience in medical leadership or oversight responsibilities, required.
Req. Certification/Licensure: Licensed Medical Doctor in the State of California, preferred. Board-certification, preferred.
Employee Value Proposition
Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core. This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts. As a member of our highly effective team of professionals, benefit eligible positions will receive:
- Company 401K
- Medical, dental, vision insurance
- Paid time-off
- Life insurance
Prospect Medical Systems has a zero-tolerance policy regarding the use of drugs and alcohol. Our Company is committed to maintaining a productive, drug free workplace that keeps employees and patients safe from harm. For this reason, we require applicants to pass a screening for drug use as a condition of employment. This includes: alcohol, marijuana, cocaine, opiates and methamphetamines.
How to Apply
To apply for this role, or search our other openings, please visit http://pmh.com/careers/ and click on a location to begin your journey to a new career with us!
We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.
EEOC is the Law: https://www.eeoc.gov/
Position Summary
Employment Status: Regular Full-time
Shift: Days
Work Schedule: Monday - Friday
Address: California - Remote
With approximately 9,000 physicians to serve our 260,000 members, Prospect Medical Systems is proud to be among the most innovative medical systems in California, Texas and Rhode Island. In the months and years ahead, we will be offering our services in other states and other markets throughout the nation. Our extensive care services range from primary care and specialty physician services to acute care hospital and skilled nursing facilities to behavioral health and wellness services.
Each of our Independent Physician Associations (IPAs) and networks support the use of advanced diagnostic and treatment tools to provide our members with convenient access to state-of-the-art healthcare. Our pledge to members is that we will give you exceptional care delivered by compassionate physicians who have a strong commitment to each and every patient. Our physicians work closely with teams of skilled nurses and other healthcare professionals.
Prospect Medical contracts with most major health plans, and we serve all product lines, including Commercial, Medicare, Medicaid, Medicare/Medicaid (Medi-Medi) and Health Insurance Exchange.
To further improve the health of the communities we serve, Prospect Medical offers comprehensive health education classes and support services through our numerous outreach programs.
Diversity and Inclusion Within Our Workforce
At Prospect Medical, we believe that a diverse and inclusive environment enriches our workforce and the communities we serve. To that end, we embrace the diversity of our coworkers, physicians, vendors and patients. We do not tolerate harassment or discrimination on the basis of race, ethnicity, religion, gender, sexual orientation, gender identity or expression, national origin, age, disability, veteran status or any other characteristics protected by law. We embrace diversity because it is our culture, and it is the right thing to do.