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Medical Director in Rhode Island at Prospect Medical Systems

Date Posted: 3/24/2019

Job Snapshot

Job Description

Medical Director

We are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care. We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives. Through collaboration, we strive to provide all of our patients and medical group members with the quality, affordable healthcare they need and deserve.

The Medical Director is responsible for providing administrative oversight of the medical components of the entire organization, including Utilization Management, Case Management, and Quality Improvement. The MD ensures that the organization operates in a manner consistent with the community standards of medical practices.

Job Responsibilities/Duties

  • Oversee the Current Review Process.  Meet with the case managers on a daily basis to discuss all members admitted to an acute care facility to ensure that appropriate case management and discharge planning is implemented, and to facilitate the member's transition to the outpatient sector.
  •  Accountable for Inpatient bedday management with a focus on utilization metrics (ALOS, Readmission Rates, ED Diversions etc). Collaborate with designated hospitalist teams to ensure appropriate coverage at all facilities, appropriate and efficient management of all patients in the inpatient setting, and appropriate discharged planning for the post acute transition period.
  • Work with Director of Health Services to provide oversight of the Case Management Department.  Review open cases regularly.  Monitor and lead Case Managers for SNP and Complex Case Management. Work with PCMH practices to ensure that goals are achieved as it relates to member satisfaction, NCQA guidelines, utilization metrics, high quality care and cost effectiveness.
  • Oversee the Skilled Facility Department.  Review all cases in house regularly with oversight and responsibility for admits, length of stay (LOS), re-directs, transition of care, observation status, re-admits conducting regular meetings with hospitalists/case managers.  Documents all data in useable format.  
  •  Provide physician oversight of the Utilization Management and Prior Authorization process to ensure the delivery of cost effective, high quality, and appropriate medical care as needed.  This includes adherence to Prospect’s denial process and compliance with industry standards and denial ratio’s.
  •  Work with all aspects of medical management to ensure compliance with outside regulatory standards.
  •  Responsible for all medical aspects of the health care delivery system implemented by the organization for those IPA divisions assigned and/or for those IPA’s where coverage is necessary.
  •  Act as the physician liaison between the organization, network providers, health plans, regulatory agencies, and other customers of the organization. Confers and consults with participating and non-participating health professionals or providers with questions related to the Utilization Management process.  Participates in retrospective medical review.  Assists in audits, as needed.


Minimum Education:  Must possess a valid Rhode Island medical license to practice without restrictions.  

Minimum Experience:  Minimum 5 years clinical experience.  

Req. Certification/Licensure:  Must be Board Certified in a specialty

Employee Value Proposition

Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core. This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts. As a member of our highly effective team of professionals you will receive:

  • Company 401K
  • Medical, dental, vision insurance
  • Paid time-off
  • Life insurance

How to Apply

To apply for this role, or search our other openings, please visit  and click on a location to begin your journey to a new career with us!

We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.

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