DIR, Medical

Salary Range: $245,179 - $392,287

Job Summary

Reporting to the Chief Medical Officer, or his/her designee, the Medical Director is responsible for providing clinical oversight for utilization, quality, care management and credentialing functions in a manner that ensures the delivery of quality, cost effective healthcare, supports organization objectives, and meets contractual and regulatory requirements.  Work is varied and highly complex, and requires a moderate high degree of discretion and independent judgment.  This position will focus on CenCal Health’s adult members and their service needs. This position will work a hybrid or remote schedule depending on business needs.

Duties & Responsibilities

• 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 supervise other Health Services staff in the future
• May participate in committee assignments such as Credentialing, Peer Review, Pharmacy & Therapeutics, and/or Quality Improvement as well as JOC (Joint Operating committee) meetings.
• Other duties as assigned, such as on-call duties related to post -stabilization care services.
• May participate in special projects such as those related to NCQA certification and implementation of the Medicare D-SNP line of business

Knowledge/Skills/Abilities

Required:

• In-depth knowledge of the principles and practices of managed care related to utilization management and case management and discharge planning
• 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
• Basic knowledge of managed healthcare as applied to government sponsored programs including Medicaid
• Strong knowledge of and ability to identify, implement, monitor an