To oversee the appropriateness and quality of care delivered through Partnership HealthPlan of California and for the cost-effective utilization of services.

• Performs Treatment Authorization Request (TAR) review and appeals to determine medical
  necessity, appropriateness of services, interprets benefits and limitations, and reviews
  claims, which are questionable in dollar amount or volume or scope of services. Assures
  that care is at all times at an acceptable level of quality.
• Confers with and counsels participating physicians who have questionable patterns of
  utilization.
• Coordinates with Utilization Management department managers and directors to provide
  daily 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 guidelines
  and treatment guidelines.
• Serves on Quality/Utilization Advisory Committee, Pharmacy & Therapeutics Committee,
  Credentials Committee and Internal Quality Improvement Committee as requested by the
  Chief Medical Officer/ May work with community provider committees and Advisory boards
  on medical issues and policies.
• Reviews potential quality issues and determines their appropriateness for review by the
  Peer Review Committee.
• Advises the Grievances and Appeals Department on preparing for, and testifying, in State
  Fair Hearings.
• Engagement of the Partnership provider network to improve quality of care and member experience.
• Performs Pharmacy Authorization review and appeals to determine medical necessity and appropriateness of prescribed medications.
• Acting as liaison to local Medical community
• Other activities related to region assignment, as assigned.
• Other duties as assigned.

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

HIRING RANGE

 $259,563.60 - $ 363,389.03

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.