| Location | San Diego, CA |
| Salary | $5,569.20–$7,364.80 Per Week |
The Medical Director of Resource Management provides clinical leadership and oversight for utilization and resource management activities across outpatient, inpatient, and post-acute care settings. This role is responsible for ensuring the clinical integrity of medical necessity reviews, promoting appropriate and cost-effective healthcare services, supporting optimal patient outcomes, and maintaining compliance with applicable regulatory and accreditation requirements.
The Medical Director partners with clinical leadership, care management teams, providers, and operational stakeholders to promote the delivery of the right care, in the right setting, at the right time.
Provide clinical oversight for medical necessity and utilization reviews across outpatient, inpatient, and post-acute care settings.
Evaluate the appropriateness of healthcare services and identify opportunities to reduce unnecessary admissions, avoidable utilization, and extended lengths of stay.
Monitor utilization patterns to identify potential overutilization and underutilization of healthcare services.
Support the development and implementation of resource management strategies and improvement initiatives.
Review authorization requests and provide clinical guidance for concurrent reviews, escalated cases, and denial management.
Conduct retrospective reviews of claims, appeals, grievances, and medical necessity determinations.
Conduct or oversee timely medical necessity determinations for outpatient services, inpatient admissions, and post-acute care.
Apply evidence-based clinical guidelines and nationally recognized utilization management criteria when evaluating the appropriateness and level of care.
Serve as the physician reviewer for complex or escalated cases requiring advanced clinical judgment.
Support timely admission status determinations and address barriers related to discharge planning and transitions of care.
Ensure medical decisions are made independently by qualified clinical professionals and are not improperly influenced by financial or administrative considerations.
Partner with physicians, primary care providers, specialists, behavioral health professionals, care management teams, and interdisciplinary teams to promote appropriate utilization and high-quality care.
Lead peer-to-peer discussions with internal and external providers regarding medical necessity, level of care, and treatment recommendations.
Educate providers and clinical staff on utilization management best practices, medical necessity criteria, and evidence-based care.
Monitor practitioner practice patterns and recommend improvement opportunities or corrective actions when appropriate.
Promote the implementation of clinical practice guidelines and evidence-based medical practices.
Monitor the continuum of care across hospitals, skilled nursing facilities, assisted living facilities, long-term acute care settings, home health, palliative care, hospice, and other appropriate care settings.
Promote quality, continuity of care, timely transitions, and cost-effective utilization of healthcare resources.
Collaborate with care management and interdisciplinary teams to support effective care planning for complex patients.
Ensure utilization management activities comply with applicable federal, state, payer, regulatory, and accreditation requirements.
Maintain oversight of internal and external appeals processes related to medical necessity determinations.
Support audit readiness, regulatory reviews, delegated oversight activities, and quality improvement initiatives.
Participate in or chair committees such as credentialing, pharmacy and therapeutics, utilization management, quality, and other clinical governance committees.
Develop, review, and implement medical policies and clinical protocols.
Utilize healthcare data, reporting tools, and analytics to monitor utilization trends and identify opportunities for improvement.
Support the development of tools and dashboards to measure resource utilization, clinical outcomes, and operational performance.
Provide clinical oversight related to diagnosis coding, risk adjustment, documentation quality, and physician education.
Partner with leadership to develop strategies that improve clinical outcomes while supporting responsible healthcare resource utilization.
Serve as a strategic clinical partner to health plan and operational leadership.
Provide clinical expertise for escalated operational and utilization management issues.
Collaborate closely with medical directors, primary care providers, behavioral health leaders, care management teams, and executive leadership.
Participate in professional, regulatory, community, and organizational activities as required.
Perform other duties and responsibilities consistent with the scope of the position.
Required:
Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree from an accredited medical school.
Preferred:
Advanced degree such as an MPH, MHA, MBA, MS, or related field.
Required:
Current, active, and unrestricted medical license in the applicable state.
Current DEA registration, where required.
Board certification or board eligibility in a primary care specialty.
Current Basic Life Support (BLS) certification.
Preferred:
Advanced Cardiovascular Life Support (ACLS) certification.
Minimum of five years of clinical experience in Internal Medicine, Geriatrics, Family Medicine, or a related specialty.
At least three years of experience in utilization management, resource management, medical leadership, managed care, health plan operations, or value-based healthcare.
Experience reviewing outpatient, inpatient, and post-acute care cases.
Experience working within integrated or coordinated care delivery models is preferred.
Strong knowledge of medical necessity, utilization management, and evidence-based clinical guidelines.
Experience using nationally recognized utilization review criteria, such as InterQual or MCG.
Knowledge of Medicare, Medicaid, CMS coverage requirements, and other applicable healthcare regulations.
Strong understanding of inpatient, outpatient, and post-acute care delivery systems.
Experience with electronic health records, healthcare technology platforms, and clinical documentation systems.
Knowledge of risk adjustment, diagnosis coding, and clinical documentation improvement practices.
Strong physician-to-physician communication and negotiation skills.
Excellent written, verbal, interpersonal, and leadership skills.
Ability to analyze complex clinical information and make timely, objective medical decisions.
Strong ability to collaborate effectively with clinical and non-clinical stakeholders.
Proficiency with Microsoft Office and other relevant healthcare software applications.
This position may require work across a variety of healthcare settings, including office, clinical, hospital, post-acute care, and community-based environments. Travel between care locations may be required based on organizational needs.