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Senior Medical Director

Company: Gold Coast Health Plan
Location: Camarillo
Posted on: May 26, 2023

Job Description:

Gold Coast Health Plan will not sponsor applicants for work visas


The Senior Medical Director (SMD) is a key leadership position within Gold Coast Health Plan's Health Services Department. The SMD role will work in close coordination with the Chief Medical Officer (CMO), supporting key functions in the Health Services, Quality Improvement (QI), Pharmacy, Care Management, and Utilization Management (UM) Departments. Role works to assist the CMO in the successful execution of planning and operational responsibilities. The SMD will provide direct supervision of Utilization Management and Pharmacy Departments while also assisting with other critical functions.


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 Statement(s)

Duties and Responsibilities
--- Provides direct supervision and direction to Utilization Management Department
--- Provides direct supervision and direction to Pharmacy Department
--- Provides direct support and guidance to Credentialing staff
--- Provide direct support and guidance to Grievance and Appeals staff
--- Provides direct support and guidance to potential Quality of Care staff
--- Provides clinical and administrative support to the CMO and direct reports for all areas of Health Services, Quality Improvement, Care Management, and Pharmacy departments
--- Assures departmental conformance to CMS, DHCS, DMHC, NCQA, and other regulatory and certification agency requirements
--- Reviews quality referred issues, focused reviews and recommends corrective actions
--- Attends or chairs, at the discretion of the CMO, committees such as Utilization Management, Credentialing, Medical Advisory, Quality Improvement and Pharmacy
--- Supports development of Interdisciplinary Care Team (ICT) model and participates in ICT rounds
--- Participates in health plan on-call physician rotation
--- Assumes CMO responsibilities when CMO is unavailable due to scheduled vacation or unexpected absences

Provides clinical leadership in UM department
--- Supervises and supports Senior Director of UM.
--- Supervises and supports contracted UM physician reviewers.
--- Supports the further development of UM department
--- Ensures the evaluation and authorization of requests within all mandated timeframes.
--- Ensures the proper use of clinical criteria in the rendering of determinations based on medical necessity.
--- Provides support for nurse reviewers and manages the denial process.
--- Reviews cases with concurrent review nurses.
--- Provides medical expertise for coordination with care management.
--- Monitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost-efficiency, and continuity of care.
--- Assists with review of retrospective reviews of claims and appeals, and resolves grievances related to medical quality of care.
--- Actively participates in the functioning of the plan grievance procedures.
--- Ensures that medical decisions are rendered by qualified medical personnel based on medical necessity informed by clinical criteria and are not influenced by fiscal or administrative management considerations.
--- Ensures that the medical care provided meets the standards for acceptable medical care.
--- Ensures that medical protocols and rules of conduct for plan medical personnel are followed.
--- Develops and implements medical policies.
--- Is directly involved in the implementation of Quality Improvement activities.
--- Educates and interacts with network and group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management.
--- Stabilizes, improves, and educates the PCP and Specialty networks.
--- Works with Contracting Department in contract negotiation.
--- Identifies and resolves UM/QI issues of network practitioners.
--- Monitors practitioner practice patterns and recommends corrective action.
--- Fosters appropriate use of clinical guidelines and evidence-based medical practice.
--- Interfaces with other GCHP departments to coordinate operations and programs.
--- Utilizes IT and data analysts to produce tools used to report, monitor and improve Utilization Management.
--- Provides clinical leadership and support to medical management system implementation and configuration.
--- Participate in regulatory, professional and community activities to provide GCHP input and become knowledgeable regarding regulatory, professional and community standards.

Provides clinical leadership in Pharmacy Department
--- Supervises and supports Clinical Programs Pharmacist (CPP).
--- Works with CPP in the further development of pharmacy department programs.
--- Provides clinical expertise to pharmacy department team members.
--- Ensures the evaluation and authorization of pharmacy requests within all mandated timeframes.
--- Provides support and clinical expertise for pharmacy department programs and initiatives related to CMS, DHCS, DMHC, NCQA, and other regulatory and certification agencies.

Knowledge, Skills, and Abilities
--- Knowledge of NCQA, HEDIS, MCAS, Medi-Cal, Medicare and Pharmacy benefit management, Group/IPA practice, capitation, HMO regulations, managed healthcare systems, quality improvement, medical utilization management, risk management, risk adjustment, disease management, evidence-based guidelines, and current clinical knowledge.
--- Knowledge of management practices, human relations, consensus building and finance.
--- Excellent interpersonal communication skills, collaborative ability, and ability to positively influence physicians.
--- Excellent verbal and written technique.
--- Must be professionally respected by peers.
--- Knowledge of applicable state, federal and third-party regulations.
--- Physical capacity and personal transportation availability to commute to and from corporate offices, Staff Model Offices and provider offices and facilities as necessary.
--- Ability to abide by Gold Coast Health Plan's policies.
--- Ability to maintain attendance to support required quality and quantity of work.
--- Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA).
--- Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers.

--- Other duties as assigned.


Competency Statement(s)
--- Management Skills - Ability to organize and direct oneself and effectively supervise others.
--- Business Acumen - Ability to grasp and understand business concepts and issues.
--- Decision Making - Ability to make critical decisions while following company procedures.
--- Goal Oriented - Ability to focus on a goal and obtain a pre-determined result.
--- Interpersonal - Ability to get along well with a variety of personalities and individuals.
--- Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.
--- Time Management - Ability to utilize the available time to organize and complete work within given deadlines.
--- Consensus Building - Ability to bring about group solidarity to achieve a goal.
--- Relationship Building - Ability to effectively build relationships with customers and co-workers.
--- Presentation Skills - Ability to effectively present information publicly.
--- Delegating Responsibility - Ability to allocate authority and/or task responsibility to appropriate people.
--- Leadership - Ability to influence others to perform their jobs effectively and to be responsible for making decisions.
--- Strategic Planning - Ability to develop a vision for the future and create a culture in which the long-range goals can be achieved.
--- Ethical - Ability to demonstrate conduct conforming to a set of values and accepted standards.
--- Judgment - The ability to formulate a sound decision using the available information.
--- Communication, Oral - Ability to communicate effectively with others using the spoken word.
--- Communication, Written - Ability to communicate in writing clearly and concisely.
--- Problem Solving - Ability to find a solution for or to deal proactively with work-related problems.


Required Education: Doctorate Degree in Medicine.

Board Certification in a medical specialty.

Preferred Education: Board Certified in primary care preferred

Required Experience:
--- Minimum 5 years previous Medical Director or equivalent medical leadership role.
--- Minimum 5 years Utilization/Quality Program Management experience
--- Minimum 5 years clinical practice.
--- Minimum 5 years HMO/Managed Care experience.

Preferred Experience:
--- Peer Review, credentialing, quality improvement, medical policy/procedure development, provider contracting experience.

Computer Skills: Advanced computer skills included in the MS Office products.

Certifications & Licenses: Valid CA Driver's License.

Current California Medical license without restrictions to practice and free of sanctions from Medicaid or Medicare.

Keywords: Gold Coast Health Plan, Camarillo , Senior Medical Director, Accounting, Auditing , Camarillo, California

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