This Jobot Job is hosted by: Ashley Elm
Are you a fit? Easy Apply now by clicking the "Apply Now" button and sending us your resume.
Salary: $180,000 - $240,000 per yearA bit about us:
The Medical Director will provide leadership and address process improvement for utilization management and quality assurance programs, working closely with the Director of Medical Management, Manager Quality Assurance, CMO, and medical management staff.Why join us?
Career Advancement / Growth - We encourage and support the professional growth of its employees by providing financial assistance to further their education.
Employee benefits include a choice of HMOs or PPO plan, along with dental, vision, flexible spending accounts, long-term disability insurance, life and accident insurance.Job Details
The Medical Director will take a leading role, with Director of Medical Management, in driving Utilization Management policies, procedures, and operational process improvement. In collaboration with the Manager of Quality Assurance, the Medical Director will assume a significant role in measured performance in specified incentive programs related to quality, value, and patient care.
This position reports directly to the CMO, while the Director of Medical Management and Manager of Quality Assurance will report up to this position.
Principal Duties and Responsibilities
- Oversees the Utilization Management program, including, but not limited to, the ambulatory referral process, clinical decision making, and operational process improvement.
- Review pediatric and adult referral requests, including the management of tertiary and out of network authorization requests.
- Support, collaborate and coordinate with Manager, Quality Assurance in the development and implementation of activities to optimize reporting of quality metrics such as HEDIS, P4P, CMS Stars.
- Support, collaborate and coordinate with Manager, Member & Provider Services on health plan performance improvement programs.
- Oversees the operations of California Child Services (CCS) authorization carve outs, helping to identify CCS-eligible conditions and opportunities for process improvement to optimize CCS carve outs.
- Serve as Physician representative for performance improvement on internal and external Committees.
- Participate in educational activities and webinars to keep up to date with most current information related to performance improvement programs, including HEDIS, P4P, 5-Stars, VIIP and other payor programs as needed.
- Develop and implement teaching curriculum for primary care providers (MD, PA, NP) related to performance improvement.
- Oversees concurrent review team.
- Participate in various committees.
- Collaborate with the Director of Medical Management on the UM Work Plan, and Manager of Quality Assurance on the QM Work Plan.
- Reports Utilization Management and Quality Management activities to the Chief Medical Officer.
- Collaborate with the CMO to engage network physicians with regard to performance, cost, clinical appropriateness and authorizations.
- Assists the CMO in analysis of clinical and financial data to develop and refine management activities, investigate and define sources of variation, and ensure conformance with standards and criteria.
- Collaborates with contracting, medical management, finance, claims department, I.T/Business Intelligence, and Executive Team on programs, projects and initiatives designed to improve the quality of care provided to our members and address medical costs.
- Other duties as required from time-to-time to support and achieve organization’s mission and goals.
- MD/DO degree with active California License required.
- 5 or more years of clinical practice.
- 2 or more years of utilization review.
- Familiarity with provider management principles.
- Experience and familiarity with Performance Improvement programs and metrics preferred.
- Demonstrated effective interpersonal skills, and oral and written communications skills.
- Medical business exposure as Medical Director of IPA, Health Plan or Medical Group preferred.
- Board certification in specialty – Pediatrics or Family Medicine preferred.
- In-patient experience preferred.
Interested in hearing more? Easy Apply now by clicking the "Apply Now" button.
- Business Intelligence
- Business Process Improvement
- Claim Processing
- Clinical Practices
- Clinical Works