The Medical Director is a key member of the medical management team and will be responsible for providing physician leadership in the Medical Affairs division, serving as liaison to other CalOptima operational and support departments. The incumbent will collaborate with the other Medical Directors and clinical, nursing and non-clinical leadership staff across the organization in areas including Quality Management, Utilization and Care Management, Health Education/Disease Management, Long Term Care, Pharmacy, Behavioral Health Integration, Program for All Inclusive Care for the Elderly (PACE) as well as support departments including Compliance, Information Services, Claims, Contracting and Provider Relations.
- Provides clinical support for all areas of Medical Affairs.
- Provides strategic vision in support of program development.
- Serves as medical expertise for care management; reviews and evaluates cases with review nurses; ensures medical care provided meets the standards for acceptable medical care.
- Monitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost-efficiency and continuity of care.
- Manages medical review process; reviews prior authorization requests and conducts retrospective reviews of claims and appeals.
- Reviews and resolves grievances related to medical quality of care.
- Actively participates in the functioning of the plan grievance and appeals procedures.
- Ensures medical decisions are rendered by qualified medical personnel and are not influenced by fiscal or administrative management considerations.
- Follows medical protocols and rules of conduct for plan medical personnel.
- Develops and implements medical policies as applicable.
- Directly involved in the implementation of quality improvement activities.
- Educates and communicates with network and group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management.
- Identifies and resolves UM/QM issues of network practitioners, recommends corrective action.
- Foster Clinical Practice Guideline implementation and evidence-based medical practice.
- Collaborates with other departments i.e. Member Services, Provider Services, Claims and Contracting to coordinate operations and programs.
- Utilizes assigned data analysts to produce tools used to report, monitor and improve utilization management.
- Attends or chair committees as directed by the CMO.
- Participates in regulatory, professional and community activities to provide CalOptima input and become knowledgeable regarding regulatory, professional and community standards and issues.
- Facilitates conformance to DHCS, CMS, DMHC, NCQA and other regulatory requirements.
- Other projects and duties as assigned.
- Understand, communicate and implement regulations, policies and guidelines.
- Establish and maintain effective interpersonal relationships with all levels of staff, external stakeholders, agencies, and the public.
- Utilize computer and appropriate software (Microsoft Office Suite).
- Communicate effectively verbally and written formats.
- Work under the pressure of strict deadlines on multiple projects in a fast-paced environment.
Experience & Education:
- Current, valid, unrestricted California Physician & Surgeon’s License with Board certification in area of specialty required.
- Minimum 3 years management experience in medical management with experience in all aspects of Utilization Management required.
- Active clinical practice experience for 3+ years required.
- Prior experience in medical management required.
- NCQA, HIPAA, DHCS, DMHC or similar regulators.
- Medicare and Medi-Cal benefits and regulations, as well as its population and demographics.
- Industry and professional standards of health care, utilization management, quality improvement and other medical management functions.
- Principles and practices of healthcare, health care systems, and medical administration.