Medical Director – Utilization Management

About CalOptima
CalOptima is a county organized health system that administers publicly funded health care coverage for low-income children, adults, seniors and people with disabilities in Orange County, California. CalOptima’s mission is to provide members with access to quality health care services delivered in a cost-effective and compassionate manner. With $3.6 billion in annual revenue, CalOptima serves nearly 800,000 members, delivering services through four programs, Medi-Cal, OneCare Connect, OneCare and PACE. For the past six years, CalOptima has been rated the top quality Medi-Cal plan in California, according to the National Committee for Quality Assurance (NCQA) Medicaid Health Insurance Plan Ratings 2019–2020.

Position Summary:
The Medical Director is a key member of the medical management team and will be responsible for providing physician leadership in the Medical Affairs division, serving as liaison to other CalOptima operational and support departments. The incumbent will collaborate with the other Medical Directors and clinical, nursing and non-clinical leadership staff across the organization in areas including Quality Management, Utilization and Care Management, Health Education/Disease Management, Long Term Care, Pharmacy, Behavioral Health Integration, Program for All Inclusive Care for the Elderly (PACE) as well as support departments including Compliance, Information Services, Claims, Contracting and Provider Relations.

Position Requirements:
 Current, valid, unrestricted California Physician & Surgeon’s License with Board certification in area of specialty required.
 3 years management experience in medical management with experience in all aspects of Utilization Management required.
 5 years of active clinical practice experience required.
 Prior experience in medical management required.

CalOptima’s Medical Director must possess the ability to:
 Understand, communicate and implement regulations, policies and guidelines.
 Establish and maintain effective interpersonal relationships with all levels of staff, external stakeholders, agencies, and the public.
 Communicate effectively verbally and writing.
 Work under the pressure of strict deadlines on multiple projects in a fast-paced environment.
 Utilize and access computer and appropriate software (e.g. Microsoft Office; Word, Excel, PowerPoint) and job-specific applications/systems.

CalOptima’s Medical Director must have the knowledge of:
 NCQA, HIPAA, DHCS, DMHC or similar regulators.
 Medicare and Medi-Cal benefits and regulations, as well as its population and demographics.
 Industry and professional standards of health care, utilization management, quality improvement and other medical management functions.
 Principles and practices of healthcare, health care systems, and medical administration.

Application Process
For a complete job description and to apply online, please go to Questions can be directed to Debbie Neal, Senior Recruiter, 657-235-6891 or

Position Description »