Associate Medical Director

AllCare Management Services•Grants Pass, OR

5h•Hybrid

About The Position

This position is responsible for overseeing the day-to-day medical management activities of the department, including but not limited to utilization reviews, appeals and grievances, case consultations, and recommendations. The Associate Medical Director will assist with the development and maintenance of all medical and departmental policies and procedures to support the utilization management process. They will work with the Chief Medical Officer to establish, implement, and monitor a departmental plan to address resource and cost utilization to ensure optimal health plan member experience and corporate performance and fiscal goals are met. Additionally, this role collaborates with the Chief Medical Officer and Director of Quality/Government Relations to ensure departmental compliance with all required regulatory and accreditation agencies. The Associate Medical Director makes clinical service determinations based on medical appropriateness, utilizing applicable criteria and guidelines and can deny requests based on medical necessity and/or not meeting criteria, policy, or appropriateness.

Requirements

Doctoral degree (M.D. or D.O.) or advanced practice license, such as Nurse Practitioner or Physician Assistant.
Five years of clinical experience.
Current Oregon Medical License free of any restrictions or disciplinary action pending and able to legally and independently practice without the supervision of another licensed professional or eligible to apply for an Oregon MD/DO/NP/PA license.
Current board certification in the designated clinical field, as applicable.
Valid Oregon driver’s license & proof of current vehicle insurance.
Familiarity with the healthcare industry.
Excellent organization and time-management skills.
Excellent computer skills, including the Microsoft Office Suite (Outlook, Word, PowerPoint, and Excel).
Knowledge of and compliance with HIPAA regulations.
Ability to apply principles of logical or scientific thinking to a wide range of intellectual and practical problems.
Ability to work with nonverbal symbolism (formulas, scientific equations, graphs, musical notes, etc.,) in its most difficult phases.
Ability to work with a variety of abstract and concrete variables.
Promotes honesty, transparency, and diligence. Approaches leadership with mindset of “power with” rather than “power over” and regularly includes others in planning and decision-making. Able to make and communicate difficult decisions in the best interest of AllCare Health.
Ready to take advantage of unexpected opportunities; adapts quickly to change and is a teacher to assist with change within the organization. Commits to solving unresolved issues in an effort to collaborate and model problem solving. Proactively develop solutions to challenges, including by constantly looking at big-picture progress and thinking about people.
Enthusiasm for meeting and engaging with people. Able to put people at ease, especially when there are lines of difference. Identifies and intervenes in problematic dynamics. Listens closely to understand needs or concerns and takes steps based on that input. Gets back to people in a timely manner. Takes pride in providing clear, helpful information.
Brings a clear vision and recognizes the value of divergent perspectives. Provides equity-centered conflict transformation support, interventions, and training in the team and across departments. Commits to and understands concepts of equity, belonging, and inclusion in the workplace. Effectively works and collaborates across differences. A working knowledge and understanding of the ways implicit bias, personal identity, and power and privilege impact individuals, organizations and systems.
The employee must be able to work onsite for all scheduled shifts.
The employee must be able to travel locally, as needed.

Nice To Haves

Two years of previous experience in Utilization, Case and/or Disease Management or Wellness preferred.
Knowledge of CMS Guidelines, CPT Codes, InterQual, HIPAA, ICD-10 Codes, Milliman Care Guidelines, and NCQA preferred.
Ability to handle multiple tasks, often within time constraints.
Ability to handle stressful and dynamic work situations.
Ability to work extended hours to see issues through to resolution.
Ability to effectively communicate with all members of the health care team, members, families and fellow staff members.
Knowledge of project management and/or change management.
Excellent at identifying and implementing improvement activities and ensuring excellence.
Knowledge of research methodologies and/or data analysis.
Excellent at interpreting data and using it to solve problems and gain new insights.
Excellent at locating information and synthesizing information from various sources.
Knowledge of customer service and service recovery best practices.
Knowledge of CMS Guidelines, CPT Codes, InterQual, HIPAA, ICD-10 Codes, Milliman Care Guidelines, and NCQA preferred.
Ability to apply advanced mathematical concepts such as exponents, logarithms, quadratic equations, and permutations.
Ability to apply mathematical operations to such tasks as frequency distribution, determination of test reliability and validity, analysis of variance, correlation techniques, sampling theory, and factor analysis.
Has advanced specialized computer skills that require mastery of applicable software in such fields as graphic design, video production, technical writing, statistics and web based training.
The employee must be able to work from a home office occasionally, when needed.

Responsibilities

Assists with the development and maintenance of all medical and departmental policies and procedures to support the utilization management process.
Works with the Chief Medical Officer to establish, implement, and monitor a departmental plan to address resource and cost utilization to ensure optimal health plan member experience and corporate performance and fiscal goals are met.
Collaborates with the Chief Medical Officer and Director of Quality/Government Relations to ensure departmental compliance with all required regulatory and accreditation agencies.
Makes clinical service determinations based on medical appropriateness, utilizing applicable criteria and guidelines and can deny requests based on medical necessity and/or not meeting criteria, policy, or appropriateness.
Leads and/or participates in corporate and community committees, task forces, and project initiatives as business needs require.
Serves as a subject matter expert in Medical Management interpreting regulatory requirements and coordinating processes to support requirements.
Works with senior management to identify and develop health plan departmental objectives and strategies to maximize operations that support corporate strategies and initiatives.
Coordinates the development and annual review of medical policies, procedures, and standards for the department to ensure they meet CMS, Oregon Health Plan, and NCQA requirements.
Collaborates with Chief Medical Officer and Chief Quality and Compliance Officer to ensure departmental compliance with all required regulatory and accreditation agencies.
Serves as a professional role model while supporting the organization’s mission, vision, and values in all departmental activities.
Works with all types of members, regardless of age, ethnicity, medical or mental impairment, disability, or dissatisfaction with the Health Plan.
Participates in organizational committees, including Credentialing, Patient Care, Quality Improvement and Pharmacy Committee as needed.
Participates in departmental staff meetings, utilization management conferences, and case review sessions.
Supports Medical Management staff activities that ensure members are receiving quality and efficient member care coordination.
Ensures an optimal member experience maximizing customer satisfaction.
Serves as lead Medical Management liaison to AllCare Independent Physicians and other providers by collaborating with other health plan constituents and communicating departmental processes.
Supports Chief Medical Officer in IPA physician recruitment and credentialing efforts.
Refers situations to the Quality Committee, Corporate Compliance, Fraud & Abuse, or Legal Services when appropriate.
Ensures Medical Management departmental compliance with all confidentiality and HIPAA requirements.
Maintains punctual, regular, and predictable attendance.
Works collaboratively in a team environment with a spirit of cooperation.
Respectfully takes direction from leadership.
Meets all required training including those listed in Relias Learning Module System (LMS).
Performs other duties as assigned.