Responsibilities include care management, medical appropriateness reviews, and over 50% of the time representing company as a clinical leader with providers, provider groups, local county officials, and hospital systems. Will work on collaborative projects around HEDIS and care coordination and help build relationships.
Primary duties include, but are not limited to:
- Meet with providers and other health care stakeholders to build relationships and execute collaborative projects
- Interpret and administer company medical policies and clinical guidelines
- Generates appropriate written correspondence to providers, members, and regulatory entities.
- Working closely with clinical and non-clinical staff to ensure timely and consistent responses to members and providers.
- Identify and develop opportunities to increase medical management effectiveness and healthcare quality.
- Serves as a resource and consultant to other areas of the company including legal, compliance and medical operations
- Liaison with external regulators including the CA Department of Insurance and the CA Department of Managed Health Care.
- May chair or serve on company committees