Medical Director

Lakeside Medical Orange, CA
Prior Authorization:

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, participate in the pre-service medical necessity review of patient care.

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

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

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

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

7. Analyze and understand the major cost drivers related to the Cal MediConnect and Exchange populations, work with South UM team to target specific cost drivers (provider, process, or service), create corrective plans in driving down costs – educate/communicate with providers to implement changes in referral pattern, utilization, and management of patients, improve internal processes, study alternatives/new partnerships to provide better care.

8. From time to time, meet with individual PCP or specialist or provider group to review best practices, authorization requests and denials, utilization metrics and outcomes.

9. Participate/organize/chair UM team meetings to improve internal processes, team development and education.

10. Work closely with high risk program Medical Director specific to Cal MediConnect members.

11. Focus on Cal MediConnect and Exchange utilization management.

12. Will also perform prior auth function for ADOC/OC campus as well as for other South campuses should need arise in cross coverage, secondary/tertiary review, or medical director decision making.

13. Perform retro-claims review for outpatient and inpatient.

14. Working with UM Director, participate, support, or take lead in audit processes both internal and external.

15. May participate in health plan joint operations meetings for discussions related to UM.