Under limited supervision, the Medical Director is responsible for providing clinical oversight for utilization, quality, pharmacy 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 to high degree of discretion and independent judgment.

Essential Functions

• 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 to identify medical service issues that have an impact on plan benefits and their administration, develop action plans and monitor results.
• Identifies and analyzes, and assists in identifying and analyzing care and 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.
• Conducts clinical reviews and makes UM decisions for prior, concurrent and retro authorizations, and appeals; approves/denies or offers medical alternatives according to HPSJ’s medical review criteria.
• Establishes and maintains working relationships with providers, provider organizations and other stakeholders that supports contracting, provider relations, marketing and other organizational goals and objectives.
• Collaborates with leadership to ensure medical compliance with internal, regulatory and accreditation requirements.
• Provides medical expertise and direction for clinical policies, procedures and programs.
• Serves on Utilization Management/Quality Improvement, Peer Review and Physician Advisory Committees; serve on other committees as required.
• Represents HPSJ in a manner that promotes a positive image of HPSJ in the community.
• Assists with development of corporate and department budgets and metrics.

Required Skills

• In-depth knowledge of the principles and practices of managed care related to utilization management and/or case management and/or discharge planning.

• In-depth knowledge of the healthcare, economic or other issues affecting Medi-Cal and/or Medicare populations, providers and the underserved in San Joaquin and surrounding areas.

• Basic knowledge of managed healthcare as applied to government sponsored programs including Medicaid and SCHIP.

• 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.

• Financial acumen: Interprets and applies understanding of key financial indicators to make better business decisions.

• Strong skills in budget development and management.

• Manages complexity: Makes sense of complex, high quantity, and sometimes contradictory information to effectively solve problems.

• Decision quality: Makes good and timely decisions that keep the organization moving forward.

• Strategic mindset: Sees ahead to future possibilities and translates them into breakthrough strategies.

• Ability to execute and monitor relevant strategic and business plans.

• Resourcefulness: Secures and deploys resources effectively and efficiently; organizes people and resources to solve problems and identify opportunities.

• Plans and aligns: Plans and prioritizes work for self and others to meet commitments aligned with organization goals.

• Ensures accountability: Holds self and others accountable to meet commitments.

• Drives results: Consistently achieves results, even under tough circumstances.

• Strong collaboration skills with demonstrated ability to create and foster a collaborative 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 HPSJ.

• 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 HPSJ.

• Strong presentation skills, including the ability to tailor presentations to a specific audience, and address and interact with large groups.

• Builds networks: Effectively builds formal and informal relationship networks inside and outside of the organization.

• Organizational savvy: Maneuvers comfortably through complex policy, process and people-related organizational dynamics.

• Persuades: Uses compelling arguments to gain the support and commitment of others.

• Manages ambiguity: Operates effectively, even when things are not certain or the way forward is not clear.

• Manages projects and deliverables on time and on budget.

• Promotes and maintains, and ensures that direct reports promote and maintain an environment that supports HPSJ’s strategy, vision, mission and values.

• Strong customer service skills.

• Intermediate skills in Word and Excel.

• Ability to speak and be understood in English.

• Ability to handle confidential information with appropriate discretion.

Preferred

• In-depth knowledge of the principles and practices of quality improvement, including HEDIS.

Required Experience

• MD degree from an accredited medical school.
• Satisfactory completion of an American Council of Graduate Medical Education accredited residency program.
• At least five years clinical experience in the practice of medicine in fields related to a managed care setting. A Master’s Degree in Public Health may be substituted for two years of the required clinical experience; and
• At least five years clinical experience in the practice of medicine with Medi-Cal and/or Medicare populations; and
• At least five years supervisory experience in a healthcare setting; or
• Equivalent combination of experience.

Preferred

• Experience in quality management in a healthcare setting.

• In-depth knowledge of the principles and practices of managed care related to utilization management and/or case management and/or discharge planning.

• In-depth knowledge of the healthcare, economic or other issues affecting Medi-Cal and/or Medicare populations, providers and the underserved in San Joaquin and surrounding areas.

• Basic knowledge of managed healthcare as applied to government sponsored programs including Medicaid and SCHIP.

• 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.

• Financial acumen: Interprets and applies understanding of key financial indicators to make better business decisions.

• Strong skills in budget development and management.

• Manages complexity: Makes sense of complex, high quantity, and sometimes contradictory information to effectively solve problems.

• Decision quality: Makes good and timely decisions that keep the organization moving forward.

• Strategic mindset: Sees ahead to future possibilities and translates them into breakthrough strategies.

• Ability to execute and monitor relevant strategic and business plans.

• Resourcefulness: Secures and deploys resources effectively and efficiently; organizes people and resources to solve problems and identify opportunities.

• Plans and aligns: Plans and prioritizes work for self and others to meet commitments aligned with organization goals.

• Ensures accountability: Holds self and others accountable to meet commitments.

• Drives results: Consistently achieves results, even under tough circumstances.

• Strong collaboration skills with demonstrated ability to create and foster a collaborative 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 HPSJ.

• 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 HPSJ.

• Strong presentation skills, including the ability to tailor presentations to a specific audience, and address and interact with large groups.

• Builds networks: Effectively builds formal and informal relationship networks inside and outside of the organization.

• Organizational savvy: Maneuvers comfortably through complex policy, process and people-related organizational dynamics.

• Persuades: Uses compelling arguments to gain the support and commitment of others.

• Manages ambiguity: Operates effectively, even when things are not certain or the way forward is not clear.

• Manages projects and deliverables on time and on budget.

• Promotes and maintains, and ensures that direct reports promote and maintain an environment that supports HPSJ’s strategy, vision, mission and values.

• Strong customer service skills.

• Intermediate skills in Word and Excel.

• Ability to speak and be understood in English.

• Ability to handle confidential information with appropriate discretion.

Preferred

• In-depth knowledge of the principles and practices of quality improvement, including HEDIS.