Outpatient Services Director jobs in Costa Mesa, CA

1.       Understand, promote and manage with the principles of medical management to facilitate the right care at the right time in the right setting.

2.       As part of a team of medical directors, nurses and coordinators, participates in the pre-service medical necessity review of patient care. 

3.       Reviews prior authorization requests for medical necessity with respect to Health Plans, CMS, third-party guidelines (i.e., McKesson InterQual, American Imaging Management, USPSTF) and medical group Medical Policies and Clinical Guidelines.

4.       Does internet searches for other existing policies/guidelines/medical necessity indications for requested services in order to facilitate quality, cost-effective care.

5.       Uses individual service requests, and larger scale analytics to identify outlier trends in utilization patterns; the successful candidate will be fluent in these diagnostics and be able to effectively engage and align the provider network to improve overall performance and patient-centered outcomes.

6.       Identify high-risk patients and help coordinate care with the high-risk team.

7.       In collaboration with the Medical Director may identify needs for and participates in the development and implementation of Care Management/Utilization Management policies and procedures to promote cost-effectiveness quality medical care. 

8.       Participates in peer-to-peer discussions with providers to discuss service request decisions as well as elective care plans for member.

9.       Liaises with the appeals and grievances department and Health Plan Medical Directors when adverse determinations come under discussion.

1.       Doctor of Medicine degree.

2.       Specialty training and/or managed care experience preferred.

3.       Minimum of five years of prior clinical experience required, with at least two years of managed-care or health-plan experience preferred.

4.       Must demonstrate a strong clinical fund of knowledge.

5.       Must have familiarity with the principles of clinical research and have the ability to interpret and apply clinical guidelines and policies.

6.       Strong proficiency in MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point) and ability to conduct research over the internet.

7.       Must have excellent communications skills both verbally and written.

8.       Typing 50 words per minutes with accuracy.

9.       Ability to deal with responsibility with confidential matters.

10.    Must have strong organization skills.

11.    Ability to work in a multi-task, high stress environment.

12.    Must be able to handle multiple projects at one time, reset priorities day-to-day to meet deadlines, and know when to ask for assistance and direction when working with conflicting priorities.

13.   Must be self-motivated, self-guiding, driven, and have high personal ethics.

14.   Must have the ability to work with all levels of management and have the ability to develop positive working relationships with medical directors and company department heads.