Medical Director

The Medical Director will report to the Chief Medical Officer and provide clinical leadership and guidance in the development and measurement of the strategic approach to quality, performance improvement, and patient satisfaction, and safety.  Medical Director assists in short- and long-range program planning, total quality management (quality improvement) and external relationships, as well as, develops and implements systems and procedures for all medical components of health plan operations.

Essential Job Functions:

  • Serves as a member of the following committees of the Board of Director: Physician Advisory Committee; Pharmacy and Therapeutics Committee; Quality Improvement Committee and Utilization Management Committee (Serve as Chairperson of the committees as delegated by CMO.) Attend committee meetings as scheduled.
  • Participates in carrying out the organization's mission, goals, objectives, and continuous quality improvement.
  • Is responsible for monitoring and controlling the appropriate utilization of health care services in order to achieve high quality outcomes in the most cost-effective manner.
  • Provides physician leadership to staff and health care providers.
  • Responsible for the clinical aspects of member and provider appeal processing and decision-making.
  • Contracts and coordinate the services of peer-review organizations and individual physicians to satisfy matched-specialty reviews for utilization management and appeals decisions.
  • Collaborates with leadership team on the effective medical cost and utilization performance of the health plan and assist with the development and deployment of strategies for effective medical cost and quality of care management.
  • Supports the selection, development and maintenance of the care management information system that supports utilization management, case management and chronic care management operations.
  • Represents the company in the medical community and in general community public relations.
  • Participates in the implementation of the Credentialing Program.
  • Supports, communicates, and collaborates with case managers in order to resolve case management and referral issues.
  • Strong knowledge of common patient disease processes and usual methods of treating.
  • Knowledge of medical terminology and commonly used equipment; Knowledge of ICD9 and/or CPT coding.
  • Demonstrated thorough knowledge of health care delivery systems and HMO regulatory requirements, including DMHC and CMS compliance.
  • Ability to read, interpret and apply written regulations, guidelines and other materials.
  • Strong analytical, assessment and problem-solving skills with intermediate negotiation skills.
  • Very strong interpersonal skills, including the ability to establish and maintain effective working relationships with individual at all levels both inside and outside of the company.
  • Ability to use tact and diplomacy to diffuse emotional situations.
  • Effective oral and written communication skills, including the ability to effectively explain complex information and document according to standards.
  • Demonstrated ability to commit to and facilitate an atmosphere of collaboration and teamwork.
  • Possess knowledge of payer source documentation requirements and governmental regulations affecting reimbursement.
  • Ability to supervise and mentor staff, analyze situations independently and make appropriate decisions.
  • Ability to prepare written reports and maintain accurate records.
  • Strong analytical, assessment and problem-solving skills with intermediate negotiation skills.
  • Advanced computer skills that include MS Office.
  • Demonstrate ability to respect and maintain the confidentiality of all sensitive documents, records, discussions and other information generated in connection with activities conducted in, or related to, patient healthcare, company business or employee information and make no disclosure of such information except as required in the conduct of business.
  • Demonstrated ability to multi-task in an interrupt-driven environment and complete assignments on a timely basis.

 

Qualifications:

  • Licensed M.D. or D.O. in good standing in the state of California.
  • Board eligible or certification in their area of specialty by the American Board of Medical Specialists (ABMS).
  • MPH, MBA, or MHA Preferred.
  • Certification by the American Board of Quality Assurance and Utilization Review Physicians or the American Board of Medical Management preferred.
  • Minimum of 3 years medical leadership experience in a managed care organization or clinical setting.
  • Minimum of 5 years of clinical practice experience.
  • History of successful clinical outcomes and ability to analyze data for quality improvement and outcomes.
  • Have an understanding of quality improvement cycle processes and outcome analysis.
  • Expertise in healthcare delivery systems and quality performance improvement initiatives.
  • May be requested on occasion to travel to conferences and meetings as an organization representative. Must be able to make arrangements to attend these as required.

PLEASE APPLY & UPLOAD RESUME USING THIS LINK: https://loxo.co/job/274025

Experience :
3-5 years
Wage :
Job Location :
Bakersfield
Creation date :
09/23/2019