Medical Director

FLSA Status: Exempt
Department: Health Services​​​​​​​
Reports To: Chief Medical Officer

GENERAL DESCRIPTION OF POSITION

Responsible for the appropriateness and quality of care delivered through SCFHP and for cost-effective utilization of services. Responsible for  Medi-Cal, and Medicare lines of business.

ESSENTIAL DUTIES AND RESPONSIBILITIES

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below.

1. Performs treatment authorization review to determine medical necessity, appropriateness of services, and interpret benefits and limitations. Reviews that care is consistent with the Plan’s standards of quality.
2. Participates in concurrent review activities of inpatient and long term care plans.
3. Reviews claims that are unusual in cost, volume or scope of services.
4. Acts as liaison between SFCHP and community providers, conferring and meeting as required.
5. Coordinates with Directors of Medical Management and Quality Improvement to provide daily support and appropriate direction to staff on issues pertaining to UM and QI. 
6. Prepares and acts as a subject matter expert for all external and internal audits with regulators including: DMHC, CMS, DHCS, NCQA. 
7. Assists in developing and revising policies to support utilization management activities, including criteria and guidelines for the appropriate use of services clinical practice guidelines, and treatment guidelines.
8. May serve on Quality Improvement Committee, Utilization Management Committee, Pharmacy and Therapeutics Committee, Credentialing Committee as requested by the Chief Medical Officer.
9. The Medical Director may work with community provider committees and advisory boards on medical issues and policies.
10. Reviews Potential Quality Issues and determines their appropriateness for review by the Peer Review Committee.
11. Performs Pharmacy Prior Authorization review in support of the Pharmacy Director
12. Participates in the Grievance and Appeal process as required, including performing second-level reviews of previous denials.
13. Participates in and leads special projects and assignments as requested.
14. Ensure the privacy and security of PHI (Protected Health Information) as outlined in SCFHP policies and procedures relating to HIPAA compliance.
15. Perform other related duties as required or assigned.

REQUIREMENTS – Required (R)   Desired (D)

The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.

1. Current unrestricted license to practice medicine in the State of California. (R)
2. Board Certified in a recognized medical practice specialty. (R)
3. Five years of post-residency experience in a recognized medical specialty. (R)
4. Specialty training in Family practice, internal medicine, or geriatrics. (D)
5.  One year utilization management experience for an Independent Practice Association, medical group or HMO. (R)
6.  Knowledge and experience with MediCal and Medicare.(D)
7. Working knowledge of HEDIS, NCQA standards, Medi-Cal Managed and Medicare. (R)
8. Knowledge of the Santa Clara County medical community. (D)
9. Experience in medical review systems. (R)
10. Able to communicate effectively with health professionals and administrators, both verbally and in writing. (R)
11. Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word, Excel, and PowerPoint. (R)
12. Ability to use a keyboard with moderate speed and a high level of accuracy. (R)
13. Excellent communication skills including the ability to express oneself clearly and concisely when interacting with SCFHP internal departments, members, providers and outside entities over the telephone, in person or in writing and the ability to remain calm and de-escalate tense situations. (R)
14. Demonstrated ability to establish, nurture and maintain strong and effective working relationships with the SCFHP staff, governmental and regulatory staff, legal counsel, and others. (R)
15. Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R)
16. Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R)
17. Ability to maintain confidentiality. (R)
18. Ability to comply with all SCFHP policies and procedures. (R)
19. Ability to perform the job safely and with respect to others, to property and to individual safety. (R)
20. Maintenance of a valid California Driver’s license and acceptable driving record, in order to drive to and from offsite