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 CalOptima operational and support departments. The incumbent will collaborate with Medical Directors, clinical, nursing and non-clinical leadership staff across the organization including; Quality Management (QM), Utilization and Care Management (UM & CM), Grievances and Appeals, Population Health 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 RESPONSIBILITIES:
- Provides clinical support for all areas of Medical Affairs following medical protocols and rules of conduct for plan medical personnel, staff and develops and implements medical policies as applicable.
- Executes strategic vision in support of program development.
- Serves as the medical subject matter expert (SME) 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, concurrent reviews and retrospective reviews for Utilization Management in addition to retrospective reviews for the Appeals Department and leads discussions with peers as needed.
- Reviews and resolves grievances related to medical quality of care and actively participates in the functioning of the plan grievance and appeals processes.
- 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 UM/QM issues, e.g. implementation of quality improvement activities, of network practitioners and 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.
- Chairs or attends committees as directed by the CMO.
- Participates in regulatory, professional and community activities to provide CalOptima input and become knowledgeable regarding regulatory, professional and community standards and issues.
- Conforms and implements DHCS, CMS, DMHC, NCQA and other regulatory requirements.
- Other projects and duties as assigned.
Required Skills
- 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 clearly and concisely verbally and in writing.
- Work under the pressure of strict deadlines on multiple projects in a fast-paced environment.
- Influence others, e.g. Ensuring medical decisions are rendered by qualified medical personnel.
- Utilize and access computer and appropriate software (e.g. Microsoft Office; Word, Excel, Power Point) and job-specific applications/systems.
Required Experience
EXPERIENCE & EDUCATION:
- Medical Doctorate degree from a fully accredited university.
- Board certification in area of specialty required.
- Current, valid, unrestricted California Physician & Surgeon’s License.
- 3 years management experience in medical management with experience in all aspects of Utilization Management required.
- 5 years active clinical practice experience required.
- Medicare, Medi-Cal and MCG experience strongly preferred.
KNOWLEDGE OF:
- NCQA, HIPAA, DHCS, DMHC or similar regulators.
- Medicare and Medi-Cal benefits and regulations, as well as its population and demographics.
- Evidence-based medical guidelines (nationally recognized standards of health care), utilization management, quality improvement and other medical management functions.
- Principles and practices of healthcare, health care systems, and medical administration.
Grade: S
#LI-POST
#CB