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.
Principal responsibilities include:
Quality Management and Clinical Services Oversight:
· With the Director of Quality and Accreditation, lead efforts to meet joint Quality and regulatory requirements and accreditation standards.
· Share accountability for Medical Services NCQA requirements and improving year over year HEDIS and CAHPS performance with Director of Quality and Accreditation.
· Assist in the development of an overall strategic direction for quality improvement and accreditation.
· Develop, implement, monitor and determine outcomes of quality improvement projects and programs to achieve outstanding utilization results.
· Oversee Potential Quality Issue (PQI) and Facility Site Review (FSR) programs.
· Work with Analytics to assess and refine the Pay for Performance program.
· 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.
· 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.
· Ensure that medical decisions are rendered by qualified medical personnel, unhindered by fiscal or administrative management.
· Participate in completing assigned Prior Authorization medical necessity reviews process, resolving medically related and potential quality related issues, and issue authorizations, modifications and denials.
· Participate in the development of utilization management (UM) criteria and clinical protocols and participate in the analysis of trends to recommend policy, program and practice changes to achieve outstanding utilization results.
· 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 and accreditation.
· Outreach to and encourage providers to close GAPs in care and work collaboratively with Alameda Alliance for Health to improve quality of care and meet accreditation requirements.
· 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.
· 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.
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.
· Successful track record as a team player, collaborative style and exceptional interpersonal skills.
· Excellent oral and written communication skills.
· Experience in use of various computer system software as well as Windows and current Microsoft Office suite.