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Position Summary: 

The San Diego PACE Medical Director of Resource Management will play a critical role in promoting high value care by ensuring the clinical integrity of San Diego PACE outpatient, inpatient and post-acute care reviews through oversight of medical necessity that will lead to recommendations of appropriate, cost-conscious services to support optimal outcomes and regulatory compliance.

Essential Functions of the Job:

• Determines appropriateness and medical necessity of health care services provided to San Diego PACE members including identifying patterns in care and supporting interventions to reduce unnecessary admissions or extended stays
• Supports San Diego PACE resource management program and accompanying action plan(s), which includes strategies to ensure high-quality participant care - that participant members receive the most appropriate care in the most effective setting and  in a timely manner- Right Care, Right Place, Right Time .
• Evaluates effectiveness of resource (namely, utilization management practices) - actively monitoring for over and under-utilization.
• Educates and interacts with network providers, PACE PCPs and staff regarding best practices for San Diego PACE resource utilization management
• Assumes leadership relative to knowledge, implementation, training, and supervision of the use of the criteria for medical necessity.
• Leads and maintains the integrity of the appeals process, both internally and externally., Medi-Cal, PACE and other regulatory requirements.
• Conducts retrospective reviews of claims and appeals and resolves grievances related to medical necessity determinations
• Attends or chairs committees as required such as credentialing, Pharmacy and Therapeutics (P&T) and other committees as directed by the chief medical officer.
• Evaluates authorization requests in timely support of nurse resource management specialists, reviews cases requiring concurrent review and manages the denial process.
• Monitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost-efficiency, and continuity of care.
• Ensures that medical decisions are rendered by qualified medical personnel and not influenced by fiscal or administrative management considerations, and that care provided meets the standards for acceptable medical care.
• Ensures medical protocols and rules of conduct for San Diego PACE and network (contracted and non-contracted) medical personnel are followed.
• Develops and implements San Diego PACE Health Plan medical policies.
• Stabilizes, improves and educates primary care physicians and specialty networks; monitors practitioner practice patterns and recommends corrective actions as needed.
• Fosters clinical practice guideline implementation and evidence-based medical practices.
• Utilizes information technology and data analytics to produce tools to report, monitor and improve resource and utilization management.
• Actively participates in regulatory, professional and community activities.

Additional Duties and Responsibilities

• Will work closely with site Medical Directors and PCPs, the Behavioral Health Director and BH providers, the Director of Health Plan, and executive leadership in particular the CMO, Sr. Program Director and CFO.
• Other principal responsibilities of the role shall be to provide clinical expertise to Health Plan Operations in the form of strategic partnership as well as in the addressing of escalations that include admission status determinations, delays in discharge and the providing of clinical input for denial management, and effective, cost-conscious primary and specialty care in the outpatient setting.
• Will guide timely care determinations using CMS regulations and evidence-based practices (InterQual) while collaborating with PACE care management teams, inter-disciplinary teams, PACE PCPs and Behavioral Health providers and external providers.
• Clinical Review: Conduct or direct timely medical necessity determinations for outpatients, inpatient admissions and post-acute settings and services (SNF, ALF, LTACH, Palliative and Hospice Care and Home Health).
• Criteria Application: Use San Diego PACE Best Practices evidence-based guidelines, InterQual and CMS criteria to assess the appropriateness of acute care services.
• Peer-to-Peer: Lead discussions with PACE Site Medical Directors, Primary Care Providers and other PACE staff and external network and non-contracted providers to direct appropriate levels of care, and to support high quality of care with timely and accurate documentation.
• Provide oversight of HCC ICD 10 Diagnosis Coding, Hierarchical Category Code and Risk Adjustment Factor Scores to maximize PCP quality and timeliness of clinical care, documentation, and outcomes.
• Complex Case Management: Serve as the primary physician reviewer for escalated or complex Resource Management cases requiring expert medical judgment.
• Collaboration: Partner with resource management, care management, and Inter-Disciplinary teams to ensure consistent effective care of high quality at reasonable costs.
• Compliance & Documentation: Ensure all decisions are documented according to PACE, NCQA and CMS requirements; support audit preparedness and delegated oversight.

Job Requirements

Education Required:

• Graduate from accredited school of Medicine.
• Advanced degree such as MS, MPH, MHA, MBA preferred.

Certifications Required:

• Current Active and Unrestricted Doctor of Medicine (MD) or Doctor of Osteopathy (DO) CA License.
• DEA license.
• Current BLS.
• Board certified or eligible in primary care specialty. 
• Preferred: ACLS certification.

Experience and Required Skills:

• Minimum of 5 years in Internal Medicine, Geriatrics, and/or Family Medicine.
• PACE clinical experience preferred.
• 3 years in a resource management or medical leadership role within a managed care, health plan, or value-based care setting.

Technical Knowledge and Skills Required to Perform the Job:

• Experience with evidence-based clinical guidelines for utilization review like the preferred InterQual Guidelines, or Milliman Care Guidelines (MCG) and advanced proficiency in MS Office and medical software EPIC and QuickCap.
• Possess strong interpersonal and negotiation skills, in both physician-to-physician interactions and in those with clinical and non-clinical staff of our care management and Inter-Disciplinary Teams.
• Excellent communication skills, both written and verbal.
• Strong experience in outpatient, inpatient and post-acute case review and deep knowledge of Medicare and Medicaid/Medi-Cal regulations and CMS coverage criteria.
• PACE resource management experience preferred.

Working Conditions and Physical Requirements:

• Work is performed in a combination of clinical, office, hospital, skilled nursing facility, and community-based settings as needed.

Universal Requirements:

Pre-employment requirements include I-9, physical, positive background and reference check results, complete application, new hire orientation, pre-employment PPDs. Compliance with all mandated vaccinations and all boosters is a term and condition of employment.