What are the responsibilities and job description for the Medical Director, Clinical Operations (NCHP) position at University of California - Los Angeles Health?
Are you passionate about evidence-based medicine and improving care for Medicare Advantage members? UCLA Health Medicare Advantage Plan is looking for a dedicated and forward-thinking Medical Director, Clinical Operations to help shape the future of our plan.
In this key leadership role, you'll work closely with the Medical Director, Department of Health Services and play a vital part in scaling Health Services functions. Your work will directly support our Health Services Department in delivering high-quality, appropriate, and patient-centered care.
What you'll do:
- Provide clinical determinations for UM (prior authorizations, concurrent reviews, appeals, grievances, peer-to-peer).
- Partner with clinical and operational leaders to ensure high-quality, cost-effective care.
- Collaborate with the Pharmacy team on safe, effective medication use; participate in drug review rounds and P&T Committee.
- Contribute to interdisciplinary care team rounds for complex case management.
Note: This position is a flexible-hybrid role that requires one-day a week on-site in Los Angeles, CA.
We're seeking a dynamic and strategic individual with:
Required:
- MD or DO degree, required
- Active, unrestricted California State Medical License, required
- Completion of residency in an adult-based primary care specialty (e.g., Internal Medicine, Family Medicine, Geriatrics), required
- Board Certification in an ABMS, ABOS, or AOA-recognized specialty (preferably Internal Medicine or Family Medicine), required
- 5 or more years of direct patient care experience post residency, required
- Minimum of 2 years of experience in Utilization Management
- 2 or more years of experience working managed care
- Knowledge of Medicare Advantage experience with utilization management, quality improvement, or case management
- Ability to lead and influence in a matrixed organizational structure
- Strong verbal and written communication skills
- Strategic thinker with a collaborative, team-oriented approach
- Proficiency in EMR, health plan platforms and productivity tools
- High integrity and commitment to ethical medical practice
- Minimum of 2 years medical leadership experience
- Familiarity with evidence-based guidelines,NCD,LCD, MCG, and ICD/CPT coding
- Experience with population health and CMS STAR ratings
University of California is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age or protected veteran status. For the complete University of California nondiscrimination and affirmative action policy, see: UC Nondiscrimination & Affirmative Action Policy.