Medical Director - Denver Health Medical Plan *must reside in Colorado*

Denver Health • Denver, CO

254d • $299,700 - $494,500

About The Position

We are recruiting for a motivated Medical Director - Denver Health Medical Plan *must reside in Colorado* to join our team! We are here for life’s journey. Where is your life journey taking you? Being the heartbeat of Denver means our heart reflects something bigger than ourselves, something that connects us all: Humanity in action, Triumph in hardship, Transformation in health. The Medical Director of Managed Care functions as the Denver Health Medical Plan's Chief Medical Officer and is responsible for the development, implementation and evaluation of medical management activities carried out by Managed Care on behalf of its members. The overarching goals of these activities are to fulfill regulatory requirements, improve member care and outcomes, reduce unnecessary health care expenses, and ensure that clinical services are provided in a manner consistent with each health plan's benefits.

Requirements

• Doctorate Degree required.
• 10+ years Clinical practice experience required.
• Three years of managed care experience in utilization management, population health, disease management, health care quality improvement programs, or clinical guideline development and implementation required.
• Three years managerial experience required.
• MD-Physician - State Medical Board required.

Nice To Haves

• Knowledge of NCQA and managed care regulations/requirements for HMO, Medicaid and Medicare Advantage preferred.
• Experience working in an outsourced UM/CM/DM environment preferred.

Responsibilities

• Supports relevant functions of the Pharmacy and Quality Improvement & Accreditation Departments and utilization, care, and disease management processes.
• Serves as a liaison to the clinical departments at Denver Health.
• Responsible for educating Denver Health’s clinical providers about the Medical Plan’s benefit plans and management resources.
• Supports Managed Care’s medical management initiatives with the clinical activities in Denver Health’s inpatient and outpatient settings.
• May serve on various Denver Health Committees.
• Provides clinical oversight and support for the Medical Management areas of: Pharmacy, Quality Management and UM/CM/DM.
• Engages with Denver Health and external providers to address practice patterns to ensure member care and quality initiatives.
• Develops and monitors annual cost and utilization targets for key medical service areas.
• Implements initiatives to improve areas that do not meet established targets.
• Evaluates utilization, national and local trends and identifies interventions to optimize the utilization of resources.
• Monitors medical costs outside of Denver Health.
• Provides clinical direction to the Quality Management, Pharmacy and Medical Management Departments.
• Responsible for supporting the Quality Improvement Program for Denver Health Medical Plan and Denver Health Medicaid Choice.
• Responsible for analyzing HEDIS results for all lines of business.
• Oversees the process of reviewing quality of care concerns and remediating identified quality of care problems.
• Remains abreast of applicable contractual and regulatory quality clinical requirements.
• Works with the Quality Management, Pharmacy and Medical Management Departments on the implementation of processes, policies and programs.
• Ensures that all contractual, regulatory and accreditation requirements are met by Medical Management functional areas.
• Represents the Plan in external regulatory audits, HEDIS audits, and accreditation site reviews.
• Meets as needed with applicable regulatory agencies and contractors.
• Promotes the development of innovative programs that meet members’ healthcare needs.
• Develops and implements plans to improve employee engagement.

Benefits

• Outstanding benefits including up to 27 paid days off per year.
• Immediate retirement plan employer contribution up to 9.5%.
• Generous medical plans.
• Free RTD EcoPass (public transportation).
• On-site employee fitness center and wellness classes.
• Childcare discount programs & exclusive perks on large brands, travel, and more.
• Tuition reimbursement & assistance.
• Education & development opportunities including career pathways and coaching.
• Professional clinical advancement program & shared governance.
• Public Service Loan Forgiveness (PSLF) eligible employer.
• Free student loan coaching and assistance navigating the PSLF program.
• National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Industry: Hospitals
• Education Level: Ph.D. or professional degree