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Associate Medical Director - Ontario, CA

Optum

Last Updated: 1/26/22

Job Description

We at NAMM, a part of OptumCare, deliver a clearly differentiated level of outcome and service adherence. Come join our team and add to our bench strength as we execute on managed care 2.0 bringing together revenue optimization, appropriate utilization, unit cost management and strategic acquisitions. Quality care saves money without exception.

North American Medical Management, California, Inc. (NAMM) develops and manages clinician networks, offering a full range of services to assist physicians and other clinicians in their managed care and business operations. For over 17 years, NAMM has been an innovator in health care with a track record for quality, financial stability, extraordinary services and superior electronic capabilities. Prime Care Medical Network is a key affiliate.

The Associate Medical Director interacts with Physicians and IPA staff to ensure that patient needs are met in an efficient, timely and medically appropriate manner. The Associate Medical Director is responsible for many Medical Management functions that including but not limited to provider relations, Utilization Management and Quality Management functions. In addition, this role provides management, oversight and development for major programs and functional areas within an IPA setting. These may include medical policy review and development, patient centered medical home oversight, population management, and reporting functions. The Medical Director is also responsible for working with physicians and other providers, especially PCMH practices, to improve the quality, affordability, and member satisfaction in order to achieve the Quadruple Aim.

Primary Responsibilities:

  • Works primarily with the physician community around issues of particular patients, balancing business and clinical concerns
  • Provides limited utilization management for outpatient medical, surgical and pharmacy activity
  • Participates in medical appeals activity. May be asked to review 2nd-level overturned cases related to medical necessity/investigational issues in the context of potential medical policy updates
  • Works with the Appeals unit on appeals related to utilization management issues
  • Provides medical leadership and physician advice to the quality management area with respect to quality improvement studies, quality improvement committees, primary care assessments (both office-site assessments and medical record document reviews)
  • Performs peer reviews on quality complaints, sentinel events, and quality-of-care referrals
  • Serves as Physician Advisor for other areas within the company, including but not limited to Sales and Marketing, Underwriting, PHP, and Provider Services
  • Provides medical leadership and advice for conformance with standards and guidelines for NCQA, URAC, state and federal regulators, and other accrediting bodies
  • Acts as liaison for communication with physicians, hospitals, and other providers in the community
  • Act as the Clinical Lead for Risk Adjustment and works collaboratively with the Risk Adjustment team and IPA leadership and physicians to improve the accuracy and completeness of coding and documentation. This position requires minimum 60% time for risk adjustment efforts
  • Collaborates and engages with the IPA physicians and practices in order to implement strategies to improve the completion rate of annual wellness visits
  • Collaborates with the Quality team and IPA physicians and practices to implement strategies to improve Quality STARs measures
  • Participates in affordability strategies to include inpatient management, outpatient high risk management, site of service and specialty contracting opportunities
  • May be asked to assist with coverage of Medical Directors in areas of review and IDTC conference management
  • May be asked to review customer service and claims issues

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

  • Possess a current and unrestricted MD or DO license in California
  • Board certification in chosen specialty
  • 2+ years of experience working as a Medical Director in a managed care setting
  • 2+ years of experience in utilization management, utilization review and prior authorization
  • 2+ years of experience interacting with both group and IPA Physicians
  • Experience with inpatient/hospitalist management
  • Experience with and comfort level in supervising Advanced Practice Clinicians
  • You will be provisioned with appropriate Personal Protective Equipment (PPE) and are required to perform this role with patients and members on site, as this is an essential function of this role.
  • Employees are required to screen for symptoms using the ProtectWell mobile app, Interactive Voice Response (i.e., entering your symptoms via phone system) or a similar UnitedHealth Group-approved symptom screener prior to entering the work site each day, in order to keep our work sites safe. Employees must comply with any state and localmasking orders. In addition, when in a UnitedHealth Group building, employees are expected to wear a mask in areas where physical distancing cannot be attained.
  • Full COVID-19 vaccination is an essential requirement of this role. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination prior to employment to ensure compliance

Preferred Qualifications:

  • Prior experience working with clinical information technology systems
  • Public presentation skills

What's the first thing that happens when one of the most successful groups in Riverside County comes together with a global leader in health care? Opportunity. With NAMM joining OptumCare and the UnitedHealth Group family of companies, people like you will find increasing levels of challenge, impact and professional success. With a vibrant network of hospitals and urgent care centers, we're changing health care for the better by improving access to affordable, high quality care, and working together to improve the patient experience. That takes passion, commitment, intense focus and the ability to contribute effectively in a highly collaborative team environment. Are you with us? Learn more about this exciting opportunity to do your life's best work.(sm)

North American Medical Management, California, Inc. (NAMM California) partnered with OptumHealth in 2012. NAMM 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.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and 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, MD, DO, managed care, UM, Utilization Management, CM, Case Management, IPA, clinical informatics, Ontario, Riverside, San Bernardino, CA



Company Details

Eden Prairie, Minnesota, United States
Mission We are committed to introducing innovative approaches, products and services that can improve personal health and promote healthier populations in local communities.  Business model From its flexible delivery models to multi-payer strategy, OptumCare® is approaching care in a unique way — unlike anyone else in the marketplace...