Medical Director, Prior Auth

Medical Director, Prior Authorization

Location: Pomona/Chino, California

A leading healthcare organization is seeking an experienced Medical Director of Prior Authorization to support its provider network throughout Pomona, Chino, and the surrounding communities. This physician leader will help ensure patients receive the right care at the right time and in the appropriate setting through medical necessity review, care coordination, and strong provider relationships.

Key Responsibilities

• Review pre-service authorization requests using evidence-based clinical guidelines and organizational policies.
• Make determinations regarding approvals, denials, modifications, and redirection of care.
• Collaborate with physicians, nurses, and clinical coordinators to provide high-quality, cost-effective care.
• Identify high-risk patients and coordinate with internal care management teams to improve outcomes and reduce avoidable utilization.
• Provide cross-coverage and secondary or tertiary review for additional locations when needed.
• Conduct retrospective inpatient and outpatient claims reviews.
• Partner with network management to build strong relationships with physicians and provider groups.
• Serve as a clinical resource to providers regarding utilization management, authorization criteria, and documentation requirements.
• Participate in grievance, appeal, quality improvement, and peer-review activities.
• Counsel providers following grievance and appeal determinations and assist with corrective action plans.
• Attend onsite department meetings and training sessions as needed.

Qualifications

• Doctor of Medicine degree required.
• Active, unrestricted California medical license required.
• At least five years of clinical experience.
• Two or more years of managed care, health plan, utilization management, or prior authorization experience preferred.
• Board certification preferred; board-eligible physicians will be considered.
• Strong clinical knowledge and the ability to interpret and apply medical guidelines.
• Experience evaluating complex clinical information and making sound medical-necessity decisions.
• Excellent written and verbal communication skills.
• Strong organizational skills with the ability to manage competing priorities in a fast-paced environment.
• High level of professional ethics and discretion when handling confidential information.
• Proficiency with Microsoft Office and online clinical research tools.
• Ability to attend onsite meetings and training in the Pomona/Chino area when required.