Department(s): Medical Management
Reports to: Deputy Chief Medical Officer (DCMO)
FLSA status: Exempt
Salary Grade: V - $266,000 - $464,068

About CalOptima Health

CalOptima Health is the single largest health plan in Orange County, serving 880,000 members, or one in four residents. Our motto — "Better. Together.” — is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community’s health. If you’re looking for an opportunity to work for an organization dedicated to improving local health care and serving the needs of the most vulnerable, we encourage you to join CalOptima Health.

About the Position

The Medical Director is a key member of the medical management team and will be responsible for providing physician leadership in the Medical Management division, serving as liaison to other CalOptima Health 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 Technology Services, Claims, Contracting and Provider Relations.

Duties & Responsibilities:

• Cultivates and promotes a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
• Directs and assists the team in carrying out department responsibilities and collaborates with the leadership team and staff to support short- and long-term goals/priorities for the department.
• Provides clinical support for all areas of Medical Management.
• Provides strategic vision in support of program development.
• Serves as medical expertise for care management; reviews and evaluates cases with review nurses; ensures medical care provided meets the standards for acceptable medical care.
• Monitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost-efficiency and continuity of care.
• Manages medical review process; reviews prior authorization requests and conducts retrospective reviews of claims and appeals.
• Reviews and resolves grievances related to medical quality of care.
• Actively participates in the functioning of the plan grievance and appeals procedures.
• Ensures medical decisions are rendered by qualified medical personnel and are not influenced by fiscal or administrative management considerations.
• Follows medical protocols and rules of conduct for plan medical personnel.
• Develops and implements medical policies as applicable.
• Directly participates in the implementation of quality improvement activities.
• Educates and communicates with network and group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management.
• Identifies and resolves Utilization Management/Quality Management issues of network practitioners, recommends corrective action.
• Fosters Clinical Practice Guideline implementation and evidence-based medical practice.
• Collaborates with other departments i.e., Member Services, Provider Services, Claims and Contracting to coordinate operations and programs.
• Utilizes assigned data analysts to produce tools used to report, monitor and improve utilization management.
• Attends or chair committees as directed by the DCMO.
• Participates in regulatory, professional and community activities to provide CalOptima Health input and become knowledgeable regarding regulatory, professional and community standards and issues.
• Facilitates conformance to Department of Health Care Services (DHCS), Centers for Medicare & Medicaid Services (CMS), Department of Managed Health Care (DMHC), National Committee for Quality Assurance (NCQA) and other regulatory requirements.
• Provides clinical support to audit and oversight as it relates to delegation oversight, over and under-utilization, access and availability, and fraud and abuse.
• Completes other projects and duties as assigned.

Experience & Education:

• MD/DO degree from a fully accredited university required.
• Current, valid, unrestricted California Physician and Surgeon’s License with Board certification in area of specialty required.
• 5 years of active clinical practice experience required.
• 3 years of experience in medical management with experience in all aspects of utilization management required.
• Experience in developing clinical guidelines and medical policies.
• Experience in implementing clinical policies and procedures in areas of utilization management , care management and quality improvement.
• An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying.

Physical Demands and Work Environment:

The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Physical demands: While performing duties of job, employee may be required to move about the organization. Employee must be able to sit for extended periods of time, as well as work at the computer for long periods. Employee is required to use hands and fingers, especially for typing on the computer and using the mouse. Employee must be able to communicate, particularly for regular phone use, in meetings, and face-to-face interaction. Occasional travel to off-site locations is required.

• Work Environment: Typical office environment with minimal to moderate noise levels and controlled office temperatures.

About our Benefits & Wellness options:

At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, work schedules that allow every other Friday off (9/80 schedule), and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. Employees also have access to 457(b) retirement plans with pre/post-tax contribution options.

CalOptima Health is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics. __

If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability.

Required Skills

Required Experience