Regional Medical Director

Job description

Overview To oversee the appropriateness and quality of care delivered through Partnership HealthPlan of California and for the cost-effective utilization of services. Responsibilities: - Performs Treatment Authorization Request (TAR) review and appeals to determine medicalnecessity, appropriateness of services, interprets benefits and limitations, and reviewsclaims, which are questionable in dollar amount or volume or scope of services. Assuresthat care is at all times at an acceptable level of quality. - Confers with and counsels participating physicians who have questionable patterns ofutilization. - Coordinates with Utilization Management department managers and directors to providedaily support and appropriate direction to staff on issues pertaining to UM. - Assists in developing and revising policies to support utilization management activities,including criteria and guidelines for appropriate use of services, clinical practice guidelinesand treatment guidelines. - Serves on Quality/Utilization Advisory Committee, Pharmacy & Therapeutics Committee,Credentials Committee and Internal Quality Improvement Committee as requested by theChief Medical Officer/ May work with community...