Medical Director

Gold Coast Health Plan will not sponsor applicants for work visas.

The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California.

Amount of Travel Required: 10%

Work Culture:

GCHP strives to create an inclusive, highly collaborative work culture where our people are empowered to grow and thrive. This philosophy enables us to create the health plan of the future and do our best work – Together.

GCHP promotes a flexible work environment. Employees may work from a home location or in the GCHP office for all or part of their regular workweek (see disclaimer).

GCHP’s focuses on 5 Core Values in the workplace:

•    Integrity

•    Accountability

•    Collaboration

•    Trust 

•    Respect

Disclaimer: Flexible work schedule is based on job duties, department, organization, or business need.

POSITION SUMMARY

The Gold Coast Health Plan Medical Director will be a physician responsible for providing clinical leadership to the Health Care Services Department, which includes management of the physician processes in support of utilization management, care management, pharmacy and associated transactional functions. These functions include performance of prospective, concurrent, retrospective utilization, member appeal and grievance reviews, and non-UM transactional work including but not limited to facilitating Gold Coast Health Plan’s interdisciplinary care team case conferences, Peer to Peer conference calls with network providers, assisting the Quality Improvement Department implement managed care accountability set (MCAS) initiatives, participating as a member of Gold Coast Health Plan’s UM, and Quality Committees, and providing retrospective provider claims dispute reviews.

The Medical Director is responsible for the day-to-day clinical determinations and transactional operations of Health Care Services. He/She is responsible for the monitoring and oversight of the UM functions performed within Health Care Services the delivery and review of defined metrics to validate business unit/program effectiveness and escalate to Gold Coast Health Plan’s Senior Medical Director the need for appropriate resources available to meet department needs and/or regulatory requirements. He/She is charged with ensuring compliance with requirements for all regulatory and accreditation authorities related to the department’s work and is responsible for ensuring departmental processes are applied and followed by Health Service associates who perform UM and transactional work.

The Gold Coast Health Plan Medical Director works collaboratively with Health Care Services and other appropriate Gold Coast Health Plan departments across product lines to identify and address opportunities to improve clinical quality, member satisfaction, reduce administrative cost and support department and organizational business goals. The Gold Coast Health Plan Medical Director will be responsible for engaging in organization-wide quality improvement efforts and promoting a culture of continuous improvement throughout the organization, and contracted provider partners. 

Reasonable Accommodations Statement

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

ESSENTIAL FUNCTIONS

Key Responsibilities

These functions are ongoing and happen simultaneously. The Gold Coast Health Plan Medical Director should be comfortable multi-tasking, prioritizing responsibilities, and adapting to changes.

•    Provide clinical and policy expertise for all aspects of physician UM serving as the representative on relevant projects including system implementation, service area and product expansion.

•    Work together with the Health Care Service Senior UM Director, Senior Care Management Director, and Director of Pharmacy to monitor UM, CM and Pharmacy processes to identify opportunities for improvement and efficiency.

•    Manage team-specific and/or departmental projects, as assigned by Gold Coast Health Plan Chief Medical Officer or the Gold Coast Health Plan Senior Medical Director.

•    Escalate to Senior Medical Director, regulatory or public facing risks including root cause analysis and any