Director, Medical Management

Medix is looking to hire a Director of Medical Management (RN) to join a not-for-profit organization in San Diego, CA. This role will ensure the highest quality of care is provided to the clients and members, providing oversight to the quality management, utilization management and credentialing functions of the organization.

Responsibilities:

• Develop, implement and update medical management programs in the areas of utilization management, case management, quality improvement, credentialing and member/provider appeals to remain current with health care trends and legislative requirements.
• Direct responsibility for the department's operations for quality management including credentialing, member and provider appeals, utilization management including inpatient, outpatient and high risk case management and maintaining positive relationships with the Medical Directors, Health Plan Representatives, Senior Team and Clients.
• Responsible for maintaining Client's delegated status for utilization management and credentialing with all contracted health plans. Review and assist in the negotiations of health plan delegation agreements on an annual basis.
• Develop, review and revise departmental policies and procedures at least annually to ensure current legislative and regulatory compliance.
• Ensure staff recruitment and selection process and performance evaluations are completed in a fair and consistent manner.
• Supports vision of the Senior Team. Actively participates in developing solutions to strategic issues.
• Works collaboratively with other Senior Team members and department managers for high quality MSO services.

Requirements / Experience:

• Three to five years experience at a senior level in medical management in a managed care, health plan, or medical group setting.
• Bachelor of Science Degree, Master's Level preferred.
• Current unrestricted California Registered Nurse licensure. Reliable transportation, valid California Driver's license and proof of insurance.

Schedule:

• Monday- Thursday 6:30 am- 5:00 pm, closed on Fridays
• Must be available to participate in team meetings on site as needed

Pay range:

$130,000-170,000 BOE