Medical Director

US-CA-Alameda
4 months ago
Job ID
2017-1661
# of Openings Remaining
1
Experience (Years)
5

Overview

The Medical Director is a member of the Medical Management Department of the Alameda Alliance for Health (“health plan”), and assists the Chief Medical Officer in developing and implementing clinical policy designed to meet the DHCS triple aim: improving the patient experience of care; improving the health of populations; and reducing the per capita cost of health care.  Medical Directors lead one of two distinct areas: Quality Management or Clinical Services (utilization and case/disease management).  The Medical Director serves as the liaison to the provider network as well as key county, agency and other community programs on behalf of the Alliance.

Responsibilities

Principal responsibilities include:

 

Clinical Services Oversight:

· Ensure that medical decisions are rendered by qualified medical personnel, unhindered by fiscal or administrative management.

· Lead efforts to meet UM, Case & Disease Management regulatory requirements and accreditation standards.

· Ensure that medical care meets standards for acceptable medical care and establish  comprehensive, understandable standards of clinical care that identify desirable, observable characteristics of care, based on state-of-the art, community, state and national practice guidelines.

· Lead assigned Prior Authorization medical necessity review process, resolving medically related and potential quality related issues, and issue authorizations, modifications and denials.

· Develop utilization management (UM) criteria and clinical protocols and analyze trends to recommend policy, program and practice changes to achieve outstanding utilization results.

· Assist in the development of an overall strategic direction of utilization management and case/ disease management.

· Participate in the Health Care Quality Committee, Pharmacy and Therapeutics Committee, and Peer Review & Credentialing Committees as well as work with ad-hoc physician and provider committees.

· Monitor physician compliance with contractual responsibilities in conjunction with the Provider Services department, particularly in the areas of utilization review and case/disease management.

· Encourage providers to manage effectively the delivery of health care and Alliance members to use the delivery network effectively and appropriately.

· Assist in the clinical oversight of the health education programs and services, and ensure that the needs of members for health education services are met.

· Provide oversight of member communication that has clinical information.

· Perform other duties as requested.

 

Quality Management Oversight:

 

· Lead efforts to meet Quality Improvement regulatory requirements and accreditation standards.

· Lead efforts to achieve outstanding HEDIS and CAHPS results.

· Lead PQI and FSR programs.

· Ensure that medical decisions are rendered by qualified medical personnel, unhindered by fiscal or administrative management.

· Lead assigned Prior Authorization medical necessity review process, resolving medically related and potential quality related issues, and issue authorizations, modifications and denials.

· Assist in the development of an overall strategic direction of continuous quality improvement and accreditation programs.

· Participate in the Health Care Quality Committee, Pharmacy and Therapeutics Committee, and Peer Review & Credentialing Committees as well as work with ad-hoc physician and provider committees.

· Monitor physician compliance with contractual responsibilities in conjunction with the Provider Services department, particularly in the areas of quality improvement, including access and availability, initial health assessment and quality improvement projects and evaluations.

· Develop, implement, monitor and determine outcomes of quality improvement projects and programs to achieve outstanding utilization results.

· Perform other duties as requested.

 

Additional Duties:

 

· Serve as intermediary between the Alliance and providers, maintain effective and consistent communications and professional relationships with providers and represent the concerns and recommendations of physicians.

· Assist in recruitment and orientation of participating health plan providers.

· Consult in the development and implementation of new products and benefits.

· Assist in promoting the use of web technology by physicians and consumers in conjunction with the health plan’s strategies.

· Complete other tasks/projects as assigned by the Chief Medical Officer.

 

 

ESSENTIAL FUNCTIONS OF THE JOB


· Hire, supervise and train staff.

· Work with the Chief Medical Officer and providers in the community to develop and advocate for programs and delivery systems that provide high quality, cost effective services (e.g. academic detailing, physician/clinic provider meetings).

· Perform continuing evaluation and modification of the health plan’s programs regarding the quality and efficiency of health care delivery.

· Assist in the development of first-rate, collaborative clinical management teams and supports inter-plan communication, cooperation and collaboration.

· Coordinate with the Chief Medical Officer to provide support and appropriate direction to staff on UM issues. (e.g. prior authorizations, PQI, clinical case reviews and dispositions, clinical grievances etc.).

· Assist in developing and revising policies to support UM activities, including criteria and guidelines for appropriate use of services, clinical practice guidelines and treatment guidelines.

· Comply with the organization’s Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.

 

 

PHYSICAL REQUIREMENTS

 

· Constant and close visual work at desk or computer.

· Constant sitting and working at desk.

· Frequent data entry using a keyboard and/or mouse.

· Frequent use of telephone head set.

· Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.

· Frequent lifting of folders and various objects weighing between 0 and 30 lbs.

· Frequent walking and standing.

Qualifications

EDUCATION OR TRAINING EQUIVALENT TO:

 

· Current Doctor of Medicine, active, unrestricted licensed in the State of California, Board certified.

· MPH and/or MBA strongly desired.

 

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:

 

· Two years experience in a managed care environment, physician group management or integrated health care system management.

· Five years experience in the practice of medicine.

· Minimum three years supervisory experience.

 

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):

 

· Experience and current knowledge in clinical program administration, including utilization management and/or quality management.

· Proven track record with tangible results in clinical quality improvement and cost management.

· Ability to think strategically and bring vision to the position.

· Ability to integrate clinical and financial data for improved management of clinical programs.

· Ability to develop and maintain successful working relationships with external constituents, physicians, hospitals, ancillary providers, regulators, government officials and the media.

· Knowledge of California public health care programs.

· Experience serving culturally diverse populations.

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