Director, Medical Jobs

Salary Range: $245,179 - $392,287

Reporting to the Chief Medical Officer, the Medical Director is responsible for providing clinical oversight for utilization, quality, care management and credentialing functions in a manner that ensures the delivery of high quality, cost effective healthcare. You will support and own key organization objectives and ensure CenCal Health meets contractual and regulatory requirements. Your primary focus will be on CenCal Health's adult members and their service needs.

Duties and Responsibilities

• Dedicated to process improvement and organizational efficiencies
• Clinical oversight and development of care management strategies and opportunities
• Provides clinical leadership for medical management functions, assists subordinate managers in resolving medical claims review, grievances, appeals, and other medical management issues
• Conducts clinical reviews and makes UM decisions for prior, concurrent (hospital/ skilled nursing facility) and retro authorizations, and appeals; approves/denies or offers medical alternatives according to CenCal Health medical review criteria; willingness to outreach to providers by phone and in person as needed; develops UM policies and procedures in coordination with Health Services staff
• Works closely with the CMO and other medical directors to identify medical service issues that have an impact on plan benefits and their administration, develop action plans and monitor results
• Identifies, analyzes, and assists in identifying quality issues and trends; makes recommendations based on findings, develops and implements agreed upon changes
• Other duties as assigned
• Provides clinical expertise needed to effectively and efficiently resolve complex, controversial and/or unique administrative circumstances; this includes working with internal and external groups
• Establishes and maintains working relationships with providers, provider organizations and other stakeholders that support contracting, provider relations, marketing and other organizational goals and objectives
• Works collaboratively with the Pharmacy team on clinical appropriateness of medication utilization

Required:

• In-depth knowledge of standard contract components and contract language specific to healthcare
• In-depth knowledge of the healthcare, economic or other issues affecting Medi-Cal and/or Medicare populations, providers and the underserved in Santa Barbara and San Luis Obispo Counties and surrounding areas
• Very strong interpersonal skills, with the ability to establish and maintain effective working relationships with individuals at all levels inside and outside of CenCal
• In-depth knowledge of audit, control and monitoring processes, and the ability to effectively implement and maintain them
• Strong presentation skills, including the ability to tailor presentations to a specific audience, and address and interact with large groups
• Strong collaboration skills with demonstrated ability to create and foster a collaborative, team based, work environment, maintain effective, high performance teams, and organize people and resources to solve problems and identify business opportunities
• Ability to create, execute and monitor relevant strategic and business plans
• Strong knowledge of and ability to identify, implement, monitor and analyze relevant metrics models, and implement effective interventions based on results
• In-depth knowledge of the principles and practices of managed care related to utilization management and case management and discharge planning
• Basic knowledge of managed healthcare as applied to government sponsored programs including Medicaid

Education and Experience

• 3-5 years clinical experience in the practice of medicine
• MD/DO degree from an accredited medical school
• Unrestricted license to practice medicine in the State of California, issued by the State Board of Medical Examiners, which meets the Health Plans credentialing and re-credentialing requirements
• Satisfactory completion of an American Council of Graduate Medical Education or American Osteopathic Association accredited residency program.
• 3-5 years of experience doing Medi-Cal and Medicare Utilization Management/Case Management for a Health Plan, IPA, or other similar medical management entity is preferred.