Medical Director

Description

Salary Range: $245,179 - $392,287

Job Summary

Reporting to the Chief Medical Officer, or his/her designee, the Medical Director is responsible for providing clinical oversight for utilization, quality, care management and credentialing functions in a manner that ensures the delivery of quality, cost effective healthcare, supports organization objectives, and meets contractual and regulatory requirements. Work is varied and highly complex, and requires a moderate high degree of discretion and independent judgment. This position will focus on CenCal Health’s adult members and their service needs. This position will work a hybrid or remote schedule depending on business needs.

Duties & Responsibilities

• Provides clinical leadership for medical management functions; assists subordinate managers in resolving medical claims review, grievances, appeals, and other medical management issues
• Works closely with the CMO and other medical directors to identify medical service issues that have an impact on plan benefits and their administration, develop action plans and monitor results
• Identifies, analyzes, and assists in identifying quality issues and trends; makes recommendations based on findings; develops and implements agreed upon changes
• Provides clinical expertise needed to effectively and efficiently resolve complex, controversial and/or unique administrative circumstances. This includes working with internal and external groups
• Conducts clinical reviews and makes UM decisions for prior, concurrent (hospital/ skilled nursing facility) and retro authorizations, and appeals; approves/denies or offers medical alternatives according to CenCal Health medical review criteria; willingness to outreach to providers by phone and in person as needed; develops UM policies and procedures in coordination with Health Services staff
• Works collaboratively with the Pharmacy team on clinical appropriateness of medication utilization
• Establishes and maintains working relationships with providers, provider organizations and other stakeholders that support contracting, provider relations, marketing and other organizational goals and objectives
• Dedicated to process improvement and organizational efficiencies
• Clinical oversight and development of care management strategies and opportunities
• May support population health activities
• No current direct reports, the position may supervise other Health Services staff in the future
• May participate in committee assignments such as Credentialing, Peer Review, Pharmacy & Therapeutics, and/or Quality Improvement as well as JOC (Joint Operating committee) meetings
• Other duties as assigned, such as on-call duties related to post -stabilization care services
• May participate in special projects such as those related to NCQA certification and implementation of the Medicare D-SNP line of business

Qualifications

Knowledge/Skills/Abilities

Required:

• In-depth knowledge of the principles and practices of managed care related to utilization management and case management and discharge planning
• In-depth knowledge of the healthcare, economic or other issues affecting Medi-Cal and/or Medicare populations, providers and the underserved in Santa Barbara and San Luis Obispo Counties and surrounding areas
• Basic knowledge of managed healthcare as applied to government sponsored programs including Medicaid
• Strong knowledge of and ability to identify, implement, monitor and analyze relevant metrics models, and implement effective interventions based on results
• In-depth knowledge of standard contract components and contract language specific to healthcare
• In-depth knowledge of audit, control and monitoring processes, and the ability to effectively implement and maintain them
• Understanding of population health concepts and social determinants of health
• Very strong facilitation, problem solving and conflict resolution skills
• Ability to create, execute and monitor relevant strategic and business plans
• Strong collaboration skills with demonstrated ability to create and foster a collaborative, team based, work environment, maintain effective, high performance teams, and organize people and resources to solve problems and identify business opportunities
• Very strong interpersonal skills, with the ability to establish and maintain effective working relationships with individuals at all levels inside and outside of CenCal. Effective building teams and consensus
• Very strong oral and written communication skills, with the ability to communicate professionally, effectively and persuasively to diverse individuals and groups inside and outside of CenCal
• Strong presentation skills, including the ability to tailor presentations to a specific audience, and address and interact with large groups
• Demonstrated ability to articulate and embrace organizational values, integrate into management practices, and foster their manifestation among staff
• Strong customer service skills
• Strong project management skills
• Intermediate skills in Word and Excel
• Ability to supervise staff, and ensure that direct reports supervise staff, in a manner that maximizes employee performance and business results
• Ability to speak and be understood in English
• Ability to handle confidential information with appropriate discretion

Education & Experience

• MD/DO degree from an accredited medical school
• Satisfactory completion of an American Council of Graduate Medical Education or American Osteopathic Association accredited residency program
• 3-5 years clinical experience in the practice of medicine
• 3-5 years experience doing Medi-Cal and Medicare Utilization Management/Case Management for a health plan, IPA, or other similar medical Management entity is preferred.
• Unrestricted license to practice medicine in the State of California, issued by the State Board of Medical Examiners, which meets the Health Plan’s credentialing and re-credentialing requirements
• Board Certification required.
• Valid California driver license with a clean driving record and reliable transportation or, the ability to obtain transportation on demand in the counties served by CenCal if prohibited from getting a driver license due to a medically documented disability

Salary : $245,179 - $392,287