MSO MEDICAL DIRECTOR - MEDICARE UNIT

The Medical Director will play a pivotal role in leading and overseeing clinical and operational programs within NEMS MSO, with a primary focus on the Medicare Advantage line of business. This role is essential in ensuring clinical excellence, regulatory compliance, and operational efficiency. Key areas of responsibility include Utilization Management, Case Management, Quality Improvement, Risk Adjustment, and provider engagement.  The Medical Director will collaborate with multidisciplinary teams, payers, and providers to improve clinical outcomes, enhance operational efficiencies, and support organizational goals.

ESSENTIAL JOB FUNCTIONS:

1. Utilization Management (UM):

• Provide clinical oversight and leadership for UM processes, ensuring timely and evidence-based medical decision-making.
• Review and approve prior authorization requests, appeals, and other medical determinations in alignment with regulatory requirements and organizational policies.
• Analyze utilization trends and identify opportunities for improving efficiency and reducing unnecessary costs.
• Collaborate with health plan partners to align UM strategies and ensure compliance with CMS, DHCS, and Medicare Advantage program requirements.

2. Case Management (CM):

• Support and guide the Case Management team in developing care plans for high-risk, high-cost patients, ensuring optimal resource utilization and improved health outcomes.
• Oversee transitions of care, ensuring seamless coordination between inpatient and outpatient settings.
• Monitor patient outcomes and implement strategies to address barriers to care for vulnerable populations.
• Evaluate the quality of case management interventions and outcomes to ensure a balance between patient-centered care, operational efficiency, and cost management, while maintaining the highest standards of clinical quality.

3. Risk Adjustment and HCC Coding:

• Collaborate with providers and coding teams to optimize accurate HCC coding and documentation.
• Lead educational initiatives to improve risk adjustment factor (RAF) scores and ensure accurate coding practices.
• Analyze risk adjustment data to identify trends and implement strategies for improvement.

4. Quality Improvement:

• Investigate and resolve member grievances related to quality-of-care issue. Collaborate with health plan partners to align QI strategies and ensure compliance with CMS, DHCS, and Medicare Plan requirements.
• Work closely with the Quality team to develop and implement clinical quality improvement initiatives.
• Monitor quality metrics (e.g., HEDIS, STAR ratings) and implement corrective actions to improve performance.
• Analyze quality data and collaborate with internal and external stakeholders to drive continuous improvement.

5. Provider Collaboration:

• Serve as a clinical resource and advisor to NEMS FQHC regarding best practices; serve as a liaison between MSO and its network providers to ensure alignment on organizational priorities and clinical goals.
• Conduct peer reviews and provide feedback to ensure compliance with clinical standards.
• Lead educational sessions, provider meetings, and collaborative efforts to enhance understanding of UM, CM, QI, and Risk Adjustment initiatives.
• Facilitate provider education on Medicare Advantage-specific requirements and quality initiatives.
• Address provider concerns and promote strong partnerships to improve patient care and operational efficiency.

6. Leadership and Strategy:

• Partner with leadership to align clinical strategies with organizational goals.