Senior Medical Director, Policy & Outcomes
Alura Workforce Solutions | Direct Hire | Full Time
Location: Inland Empire, CA (Hybrid: on site Tuesday through Thursday, remote Monday and Friday)
Compensation: $280,841.60 to $393,182.40 annually, plus comprehensive benefits
About the Opportunity
Alura Workforce Solutions is partnering with a large, mission-driven California health plan to find a Senior Medical Director, Policy & Outcomes. This is a hands-on medical policy leadership role for a physician who enjoys policy work and wants to own it: building, maintaining, and defending the clinical guidelines and policies that drive member outcomes and health plan performance.
The ideal candidate is a physician leader with direct health plan or managed care plan leadership experience who wants to stay close to the work, partner across departments, and lead a team of physicians. California managed care policy knowledge is a significant advantage.
The Role
Reporting to the Vice President of Health Services, the Senior Medical Director, Policy & Outcomes is responsible for strategic oversight of the plan's Medical Policies and clinical leadership around member health outcomes. This leader:
- Oversees day-to-day operations for developing, executing, leading, and updating guidelines, policies, clinical pathways, and communications that support effective health outcomes and health plan performance under DHCS, DMHC, CMS, and CCA clinical requirements
- Serves as the accountable medical leader for clinical activities including quality management, grievance and appeals, and appropriate clinical resource stewardship
- Partners with cross-functional departments to monitor the impact of policy outcomes through regular reporting, metrics, initiatives, and other improvement activities
- Supports regulatory audits across all relevant domains
- Incorporates the plan's Quality Program goals, including but not limited to HEDIS, CAHPS, and NCQA Accreditation
Required Experience and Education- Seven (7) years of post-residency experience in a recognized medical specialty or practice, including at least three (3) years of medical administrative experience
- A minimum of five (5) years of managed care or health plan leadership experience, with a proven track record of leading high-performing physician teams
- Direct health plan or managed care plan leadership is required. Experience limited to an IPA or medical group does not meet this requirement
- Experience working with clinical practice guidelines and evidence-based criteria sets
- Exposure to working with regulatory agencies
- Doctorate of Medicine from an accredited institution
- Certification by one (1) of the American Specialty Boards
- Completion of an accredited residency program
- Active, unrestricted, and unencumbered Physician's and Surgeon's Certificate issued by the State of California. A physician certified in another state may be employed before receiving California certification, provided an application for a California certificate is filed before the date of appointment
Preferred- Medical Director experience with a California HMO or health plan
- California-specific managed care policy knowledge (out-of-state candidates will be considered)
- Medical specialty or practice experience in California
- Familiarity with local healthcare organizations and/or local practice experience
Key Qualifications
Expert-level knowledge of:
- Managed care principles
- Administrative practices and procedures, including credentialing and risk management, and the rules, regulations, policies, and standards related to managed care
- Principles of effective supervision and organization, and the methods, techniques, practices, principles, and literature of the broad field of medical sciences
- Principles of medical practice across settings (inpatient, outpatient, subacute, and similar)
- Federal and state regulatory requirements, including CMS, DHCS, DMHC, CCA, NCQA, and associated clinical policy and compliance standards
- Cost-of-care levers, utilization patterns, total cost of care initiatives, and financial drivers in value-based environments
- Managing complex grievance and appeals issues with compliance, timeliness, and defensible clinical rationale
Advanced proficiency in:
- Written and verbal communication, both clinical and operational, for cross-functional collaboration
- Policy development
- Analytical and data interpretation skills and problem solving
- Presentations
- Microsoft Word, Excel, and Access
Demonstrated ability to:
- Maintain clinical independence, keeping medical decision-making free of inappropriate administrative or financial influence
- Communicate assertively
- Effectively lead other physicians and clinical staff
- Lead with accountability
- Stay detail-oriented and organized
- Drive and execute outcomes and improvements
- Lead through change, navigating evolving regulatory landscapes, new clinical guidelines, and operational shifts
Why This Organization
This is a mission-driven health plan with a culture built around serving its members, and it brings that same commitment to its team members through a strong benefits package:
- Competitive salary
- Hybrid schedule
- State-of-the-art on-site fitness center
- Medical insurance with dental and vision
- Life, short-term, and long-term disability options
- Career advancement and professional development
- Wellness programs that support work-life balance
- Flexible Spending Account (health care and childcare)
- CalPERS retirement
- 457(b) option with a contribution match
- Paid life insurance for employees
- Pet care insurance
Pay Range
$280,841.60 to $393,182.40 annually