Medical Director - PT

Medical Director - PT

Vacancy expired!

Job Description

• Provides clinical leadership for medical management functions; assists subordinate managers in resolving medical claims review, grievances, appeals, and other medical management issues
• 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
• Provides clinical expertise needed to effectively and efficiently resolve complex, controversial and/or unique administrative circumstances. This includes working with internal and external groups
• 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 collaboratively with the Pharmacy team on clinical appropriateness of medication utilization
• Establishes and maintains working relationships with providers, provider organizations and other stakeholders that support contracting, provider relations, marketing and other organizational goals and objectives
• Dedicated to process improvement and organizational efficiencies
• Clinical oversight and development of care management strategies and opportunities
• May support population health activities
• No current direct reports, the position may supervisor other Health Services staff in the future
• May participate in committee assignments such as Credentialing, Peer Review, Pharmacy & Therapeutics, and/or Quality Improvement

Qualifications

Requires an M.D., Board certification preferred.

Board eligibility in a chosen specialty

Unrestricted license to practice medicine in the State of California, issued by the State Board of Medical Examiners, which meets the Health Plan’s credentialing and re-credentialing requirements

Experience in Utilization Management/Case Management in a clinical setting

3-5 years:At least three - five (3-5) years clinical experience in the practice of medicine in

Satisfactory completion of an American Council of Graduate Medical Education accredited residency program; family medicine or internal medicine preferred.

3-5 years:Demonstrated ability to articulate and embrace organizational values, integrate into management practices, and foster their manifestation among staff

3-5 years:Strong presentation skills, including the ability to tailor presentations to a specific audience, and address and interact with large groups

3-5 years:Very strong oral and written communication skills, with the ability to communicate professionally, effectively and persuasively to diverse individuals and groups inside and outside of CenCal

3-5 years:Very strong interpersonal skills, with the ability to establish and maintain effective working relationships with individuals at all levels inside and outside of CenCal. Effective building teams and consensus

3-5 years: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

3-5 years:Ability to create, execute and monitor relevant strategic and business plans

3-5 years:Very strong facilitation, problem solving and conflict resolution skills

3-5 years:Understanding of population health concepts and social determinants of health

3-5 years:In-depth knowledge of audit, control and monitoring processes, and the ability to effectively implement and maintain them

3-5 years:In-depth knowledge of standard contract components and contract language specific to healthcare

3-5 years:Strong knowledge of and ability to identify, implement, monitor and analyze relevant metrics models, and implement effective interventions based on results

3-5 years:Basic knowledge of managed healthcare as applied to government sponsored programs including Medicaid

3-5 years: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

3-5 years:In-depth knowledge of the principles and practices of managed care related to utilization management and case management and discharge planning

Additional Information

If you are interested in joining the team at CenCal Health, please apply at:

https://recruiting2.ultipro.com/SAN1015SBHA/JobBoard/be64234c-c47d-4274-b3c6-8cac051e31e3/?q=&o=postedDateDesc