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.
This immediate leadership opportunity will interact with Physicians and IPA staff to ensure that patient needs responsible for many Medical Management functions that including but not limited to provider relations, Utilization Management and Quality Management functions. Management, oversight and development for major programs and functional areas within an IPA setting including medical policy review and development, patient centered medical home oversight, population management, and reporting functions. Work with physicians and other providers, especially PCMH practices, to improve the quality, affordability, and member satisfaction in order to achieve the Quadruple Aim.
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. Work 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.
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 (approximately 50- 60% dedicated 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. Assist with coverage of Medical Directors in areas of review and IDTC conference management as needed.
Possess a current and unrestricted MD or DO license in California
Board certification in chosen specialty
Minimum 2+ years of experience working as a Medical Director in a managed care setting with minimum 2+ years of experience in utilization management, utilization review and prior authorization.
Minimum 2+ years of experience interacting with both group and IPA Physicians including experience with inpatient / hospitalist management.
Experience supervising Advanced Practice Clinicians
Prior experience working with clinical information technology systems
Comfortable presenting 1:1 and in group setting
Excellent communication skills
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: Optum and its affiliated medical practices are Equal Employment Opportunity/Affirmative Action employers 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. Optum and its affiliated medical practices is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.