Medical Director – CCHCA – San Francisco, CA

Summary: This Medical Director is responsible to ensure that IPA complies with Medical Management functions that include Utilization Management, Case Management, and Disease Management Programs, as regulatory agencies require and the IPA’s health plan contracts stipulate.

This Medical Director shall work collaboratively with our TPA and delegates to ensure compliance with the respective health plans and achieve the strategic goals/measures within each of those health plans. Medical Director is also responsible for network adequacy, provider engagement, and provider education.

Medical Director shares in the administrative functions that directly impact medical services and collaborates with the management team in overall planning activities. The Medical Director assures delivery of quality services to all patients and performs oversight of delegated duties to our third party administrator (TPA).

ESSENTIAL DUTIES AND RESPONSIBILITIES:

REFERRAL MANAGEMENT

· Monitor care utilization trends, communicate to the IPA providers, and make recommendations to position the organization proactively to manage trends effectively
· With the staff, develop and implement action plans, including, UM Program, plans, evaluations, oversight audits, policies and procedures, to ensure appropriate and efficient utilization of services
· Provide and/or supervise the education, guidance, assistance, and feedback to primary care physicians , specialty physicians, network provider and vendors to achieve appropriate cost-effective patient care
· Assess provider network for adequacy of services and make recommendations to staff to address service gaps

QUALITY/PATIENT EXPERIENCE

· Leads efforts with IPA providers to maximize patient experience (e.g. as measured by CAHPS), quality (as measured by P4P, HEDIS and CMS 5 Star) and other programs as they become available.
· Supports medical management, utilization management, and quality management committees

CASE/DISEASE MANAGEMENT and OTHER SPECIAL PROGRAMS

· Oversees the TPA and sub-delegates for UM activities of the Medical Group (MG) in regards to compliance with contractual Health Plan requirements, Federal and States statutes and regulations, and requirements of accrediting bodies such as the National Committee for Quality Assurance (NCQA).
· Oversee program implementation and ongoing case and disease management programs, interfacing with case managers and other TPA staff for medical advice and intervention as needed
· Monitor utilization trends and communicate program outcomes to IPA leadership and physicians
· Oversight of the TPA to ensure that the TPA promotes the appropriate utilization of programs to manage complex and/or catastrophic cases and to promote positive health outcomes through disease management interventions

COMMITTEE FUNCTIONS AND LEADERSHIP

· Lead identified initiatives or projects as appropriate.
· Attend, support, and provide presentations at IPA Board Meetings, Committee Meetings, General Membership Meetings, Physician Banquets, Recruiting, Physician Seminars, etc.
· Develop educational programs for the physician network to enhance the delivery of patient care.
· Participates in Staff Meetings, Directors Meetings, Committee Meetings and other ad-hoc meetings/seminars as needed

NETWORK MANAGEMENT/PROVIDER CONTRACTING

· Act as the main point of contact for physicians who wish to speak directly about UM decision complaints, and grievances
· Assess the adequacy of information being provided by the IPA to the IPA’s providers and assist in development of any new or revised materials
· Assist staff in development of fee schedules or payment methodologies
· Works collaboratively with the Medical Director of the TPA to provide clinical input required for the staff to create and deliver physician performance reports to enhance performance of the physician network

CLAIMS

· Assist claims staff in review of medical claims of services or other inappropriate billing practices as needed
· Assist as liaison in between the Medical Director of the TPA in training/educating the IPA providers
· Performs all other related duties as assigned.

MINIMUM QUALIFICATIONS

· M.D. or D.O. Degree from an Accredited Medical School.
· Clinical experience and private practice experience desirable.
· Managed Care experience desirable.
· Must hold a valid, current unrestricted license to practice medicine in the State of California.
· Have at least 3 years of clinical practice in direct patient care; and at least three years of medical management experience in a managed care setting.

PREFERRED QUALIFICATIONS

At least three years of experience working with indigent populations and community based programs.
Past UM experience at the IPA or Health Plan level is preferred.

BENEFITS

We are a fast growing company with a great culture. We provide medical, dental, vision, 401k and Paid Time Off (PTO). Salary is commensurate with experience. If you would like to be considered for this Medical Director position, please send your resume and cover letter (optional) to the email provided.
Related keywords: medical director, healthcare management, physician

Job Type: Full-time

Schedule: