Who We Are

Because health is personal. That's why Personify Health created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. We serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes. Together, our team is on a mission to empower people to lead healthier lives.

Learn even more about the work that drives us at personifyhealth.com.

ESSENTIAL DUTIES and RESPONSIBILITIES:

The Medical Director relies on their medical background to review claims for medical necessity for prior authorization, continued stay review and post service. The Medical Director can read, interpret, and apply medical policy, guidelines, and research to utilization review. The Medical Director has authority for issuing adverse determinations while performing medical necessity evaluation.

• Has discussions with external physicians by phone to gather additional clinical information or discuss determinations regularly, and in some instances, these may require conflict resolution skills. Some roles include an overview of coding practices and clinical documentation, grievance and appeals processes, and outpatient services and equipment, within their scope.
• Keep the team informed of clinical updates through educational opportunities by developing educational materials for staff.
• Work with the VP of Care management to establish work procedures and processes that support company and departmental standards, procedures, and strategic directives.
• Excellent verbal and written communication skills.
• Evidence of analytic and interpretation skills, with prior experience participating in teams focusing on quality management, utilization management, case management, discharge planning and/or home health or post-acute services (such as inpatient rehabilitation).
• Knowledge of the managed care industry as it relates to commercial business.
• Oversee the negotiation and implementation of cost management strategies to affect quality outcomes and reflect this data in monthly case management reviews as it relates to clinical aspects in case management and utilization review rounds.
• Exercises independence in meeting departmental expectations and meets compliance timelines.
• Ability to meet productivity, quality, and turnaround times daily.
• Ability to pass external audits to include URAC and NCQA.
• Maintain HIPPA compliance per company’s policy and procedures.
• Maintain confidentiality and minimum requirement rules.
• Complete all required yearly training per company’s expected period.

KEY COMPETENCIES:

To work in the health industries and to work remotely, it has been demonstrated that those with computer skills work better in these remote job descriptions.

UPON HIRE, must have:

• Basic computer literacy
• The ability to work on multiple screens, and proficient typing skills.
• Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, and Outlook Excellent verbal and written communication skills
• Ability to speak clearly and convey complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others.
• Ability to work independently and utilize written resources to problem solve.
• After training with our training department and 1.5 months ramp (3 months total), must have and be able to work in:
• Teams on and off camera, SharePoint, Drives as needed, VPN, UM Web or Health Notes, El Dorado, Quick Links, GIAS, ADP, Confluence, Phone system with headset, Smartsheet—there may be additional programs as it relates to particular job duties
• Knowledge of medical claims and ICD-10, CPT, HCPCS coding
• Strategic thinking with proven ability to communicate a vision and drive results
• Proficient in analysis and interpretation of clinical data
• Comfortable with multiple accountabilities and matrix management
• Proven record of strong relationships and working with diverse teams
• Demonstrated ability to work independently with excellent judgment
• Ability to work from home or in a virtual environment
• Strong interpersonal skills necessary to effectively communicate with medical personnel and members
• Analytical and problem-solving skills necessary to identify and review pertinent information
• The ability to incorporate analytical data into new or existing clinical programs to enhance quality of care
• Ability to present data analysis in written format to upper management in a clear, concise manner
• Ability to maintain an extremely elevated level of confidentiality
• Able to successfully handle competing priorities
• Experience in the Utilization Review Process which includes Prior-Authorization/Pre-Certification, Retro Reviews, Concurrent Reviews and Post Service Claims Review
• Experience in the grievance, appeals process, and ability to work on escalated issues as they arise
• Ability to provide quality oversight to personnel, process improvement, policies, and procedures
• Familiarity with National Guidelines such as MCG or InterQual, medical policy or commonly used guidelines from Specialty Colleges
• Experience in disease management with knowledge and understanding of disease progression.
• Knowledgeable of the Federal, State and ERISA regulation

This is a part-time position.

What You'll Actually Do

What You Bring to Our Team

QUALIFICATIONS:

• MD or DO degree and 5+ years of direct clinical patient care experience post residency or fellowship, which preferably includes some experience in an inpatient environment.
• Current and ongoing Board Certification in an approved ABMS Medical Specialty.
• A current and unrestricted license in the state of California and willing to obtain additional license(s), if needed. (Optional)
• No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements.
• Minimum 5 years of Utilization Review or Hospital experience required.
• Minimum 3 years of compliance related experience preferred.
• Managed Care experience preferred in utilization review and case management.

Physical and Mental Requirements:

• Ability to perform the essential job functions safely and successfully with or without reasonable accommodation, including meeting qualitative and/or quantitative productivity standards.
• Ability to maintain regular, punctual attendance.
• Ability to sit for 6-8 hours.
• Constant use of computer keyboard and mouse; repetitive use of both hands.
• Occasional to frequent twisting of neck; occasional bending of neck and at waist.

Benefits

The Highlights:

• Part-time schedule designed around your availability and life priorities
• Access to learning and development opportunities alongside full-time colleagues
• Mentorship and skill-building that translates to career advancement
• Competitive hourly compensation that values your expertise
• Technology and equipment support to set you up for success

Compensation: This position offers a base salary range of $91-$114 per hour, depending on location, skills, and experience. Part-time employees are not eligible for health benefits.

Our Commitment: Personify Health is an equal opportunity employer committed to diversity, equity, inclusion, and belonging. We cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive—because diversity is core to who we are and critical to our work in health and wellbeing.

Stay Safe: Personify Health will never ask for payment or sensitive personal information like social security numbers during hiring. All official communication comes from verified company email addresses and or our secure applicant tracking system. Suspicious requests? Report them to talent@personifyhealth.com. View all legitimate openings at personifyhealth.com/careers.