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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical oversight, quality improvement methodologies, and utilization management within healthcare settings. Capable of analyzing clinical data to drive performance improvements and ensure compliance with regulatory standards.
Highest-signal resume keywords
MD Or DO DegreeActive And Unrestricted Medical LicenseBoard Certification In A Medical SpecialtyUtilization ManagementQuality Improvement Methodologies
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical Protocol DevelopmentClinical Performance Metrics AnalysisEvidence-Based PracticesMedical Necessity ReviewsCare CoordinationData-Driven Performance ImprovementHEDISStarsValue-Based Care PrinciplesComplex Case Reviews
Soft Skills
Excellent CommunicationLeadership SkillsInterpersonal Skills
Industry Keywords
Healthcare RegulationsQuality Incentive ProgramsManaged CarePopulation HealthProvider AppealsAuthorization ReviewsDelegated Managed Care ArrangementsIPAACOClinical Pathways
About the role
Key responsibilities & impact- Provide clinical oversight and direction to ensure the quality and efficiency of healthcare services
- Develop and implement clinical protocols, guidelines, and standards
- Monitor and evaluate clinical performance metrics and outcomes
- Lead quality improvement initiatives to enhance patient care and safety
- Oversee evidence-based practices and clinical pathways
- Review clinical data to identify areas for improvement
- Partner with Quality, Care Management, and Population Health teams to improve HEDIS, Stars, preventive care, care gap closure, and utilization performance metrics
- Support identification and management of high-risk, high-cost, and high-opportunity patient populations
- Foster relationships with network physicians and healthcare providers
- Collaborate with providers on clinical issues, care coordination, and best practices
- Facilitate provider education and training
- Lead utilization management activities and ensure appropriate, effective, evidence-based use of healthcare resources
- Participate in prospective, concurrent, and retrospective utilization reviews
- Review medical necessity determinations, treatment plans, hospital admissions, and specialty referrals
- Serve as a clinical resource for complex utilization, authorization, and care management cases
- Develop and refine utilization management policies, procedures, clinical criteria, and authorization guidelines
- Analyze utilization trends, referral patterns, inpatient and outpatient utilization data, and care coordination opportunities
- Participate in appeals and peer-to-peer discussions regarding medical necessity and coverage determinations
- Provide oversight for high-risk patient management, transitions of care, and complex case reviews
- Participate in or chair Utilization Management Committee meetings
- Present utilization trends, performance metrics, and improvement opportunities to leadership
- Ensure compliance with regulatory requirements and industry standards
- Stay current on healthcare regulations and implement necessary adjustments
- Manage audits and accreditation processes
- Contribute to the IPA’s strategic plan and identify growth opportunities
- Collaborate with executive leadership on clinical and organizational objectives
- Participate in network expansion through presentations and outreach to provider prospects
- Participate in physician recruitment outreach, employment fairs, residency program events, and other prioritized events
- Participate in physician candidate interviews after initial screening
- Maintain relationships with physician candidates through final selection and onboarding
- Participate in onboarding and orientation of new physicians
- Serve as AMG Friendly Physician for the Southern California Region
Requirements
What you’ll need- MD or DO degree from an accredited medical school
- Active and unrestricted medical license
- Minimum of 5 years of clinical experience, with at least 3 years in a leadership role
- Board certification in a medical specialty
- Strong understanding of quality improvement methodologies and healthcare regulations
- Excellent communication, leadership, and interpersonal skills
- Ability to analyze complex clinical data and develop actionable insights
- Strong knowledge of utilization management, care management, population health, and value-based care principles
- Ability to conduct medical necessity reviews and evaluate clinical appropriateness using evidence-based guidelines
- Experience managing provider appeals, authorization reviews, and payer interactions
- Understanding of HEDIS, Stars, RAF, quality incentive programs, and managed care performance metrics
- Demonstrated ability to influence physician behavior through education, collaboration, and data-driven performance improvement
- Preferred: experience in an IPA, health plan, ACO, delegated medical group, managed care, or value-based care environment
- Preferred: prior experience serving as a Medical Director, Associate Medical Director, or Physician Advisor
- Preferred: experience with delegated managed care arrangements, health plan partners, and utilization management committees
- External hires must pass a background check/drug screen
Benefits
Comp & perks- Excellent medical, vision, and dental coverage
- 401k savings plan with a company match
- Flexible time off
- 9 Paid Holidays
- Competitive compensation package
- Robust benefits program