"Alerted.org

**Facility:** Corporate Offices

**City** San Diego

Department

Job Status

Regular

Shift

Day

FTE

1

Shift Start Time

Shift End Time

California Physicians and Surgeons License - Medical Board of CA

Hours** **:

Shift Start Time:

8 AM

Shift End Time:

4 PM

AWS Hours Requirement:

8/40 - 8 Hour Shift

Additional Shift Information:

Weekend Requirements:

As Needed

On-Call Required:

No

Hourly Pay Range (Minimum - Midpoint - Maximum):

$120.724 - $155.772 - $190.821

The stated pay scale reflects the range that Sharp reasonably expects to pay for this position.  The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant’s years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.

What You Will Do

The position is accountable for providing medical management and leadership to SCMG to ensure the delivery of high quality, customer responsive and cost-effective medical care on behalf of SCMG, and its members through a network of private practice physicians.

Required Qualifications

+ 5 Years clinical practice experience.

+ California Physicians and Surgeons License - Medical Board of CA -REQUIRED

Other Qualification Requirements

+ Must be Board Certified.

Essential Functions

+ Participation in Health Services Management including:Authorization or denial of hospital admissions and extended stays.Daily on-site review of the medical necessity of inpatient hospital stays with ongoing interaction with admitting physicians and/or hospitalists and concurrent review staff.Authorization or denial of outpatient procedures.Review of out of area hospital and medical care services, and out-of-network department patient management.Interaction with case management activities.Provides input on medical claims review to determine medical necessity, appropriateness of provider services, interpretation of benefits and limitations, and review of claims.Provides input on day-to-day medical care review on issues involving prior authorization, concurrent review and retrospective review of outpatient and inpatient services.Participates in and performs benefit interpretation and criteria development.Communicates with health plan clients and medical directors on utilization function.

+ Identifies physicians whose utilization and/or clinical practices are aberrant and recommends and participates in taking corrective action in both inpatient and outpatient settings. This includes education of participating physicians regarding medical group policies and procedures and monitoring of physician compliance. Develops and implements physician sanction and grievance procedures in coordination with the Executive Medical Director and Chief Medical Officer.

+ Communicates directly with providers regarding problem resolution of grievances.

+ Participates with systems integration of mutual utilization review and finance issues related to appropriate level and location of patient services.

+ Provides medical knowledge, management and resource to assigned regional councils, specialty advisory councils and other SCMG committee meetings as assigned and mutually agreed upon by other SCMG medical directors.

+ Participates with the other medical groups within the Sharp medical community to achieve efficiencies of operation whenever appropriate.Active participation in regional hospital operations meetings.Close “supervision” of the hospitalist team. Provision of performance data, feedback, etc., needed to ensure improvement of hospital utilization.Identification of low hanging fruit for improved management, i.e., pain management.

+ Other duties as assigned.

Knowledge, Skills, and Abilities

+ In-depth knowledge of medical care delivery systems, utilization management, quality assurance, peer review, contracting, benefits interpretation, provider relations, and member services.

+ Excellent interpersonal and persuasive communications skills along with leadership skills.

+ Knowledge and experience in the operations of a prepaid delivery system.

+ Ability to manage for results and good analytical and negotiation skills.

Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class