Medical Director, Quality

L.A. Care Health Plan•Los Angeles, CA

6d•$206,311 - $350,729

About The Position

The Medical Director, Quality is a key member of the Health Services team and works collaboratively with the Chief Quality and Population Health Executive. The role implements the health plan’s quality improvement strategy in collaboration with administrative and clinical leaders, providing clinical leadership and oversight to support high-quality, cost-effective, evidence-based care. This includes supporting clinical and population health improvement efforts, tracking and presenting results, monitoring clinical process measures, and overseeing regulatory readiness. The position directs network performance improvement programs and establishes new improvement activities. These include methods to track peer review, credentialing, provider performance improvement plans, site surveys, and potential clinical quality and critical event reviews. The Medical Director responds to the needs of the Chief Quality and Population Health Executive and the Board of Governors subcommittees for Compliance & Quality; leads and advises relevant credentialing, peer review, provider quality, and clinical and member advisory groups; and liaises with provider-focused departments to establish and maintain best-practice operations that support member experience and access to care. The Medical Director partners with executive leadership, clinical teams, and external stakeholders to improve outcomes, support regulatory compliance, and advance organizational goals. The position also supports population health management and practice transformation to improve quality and value of care, control total costs, elevate member experience, and advance health equity.

Requirements

Doctor of Medicine (M.D.).
At least 10 years of extensive post-medical-degree experience in clinical practice, quality improvement, and population health management.
Proven experience in a physician leadership role, including managing teams.
Board certified, preferably in a primary or medical specialty.
Active, current, and unrestricted California license.
Passion for improving quality for vulnerable populations.
Strong leadership presence and ability to lead, mentor, and motivate a team.
Ability to think strategically and take a broad, business-oriented perspective.
Strong analytical and problem-solving skills, with a data-driven approach to evaluating programs.
Exceptional communication and presentation skills to convey complex medical concepts to diverse audiences.
Ability to review and assess clinical cases for potential quality issues and legal cases for severity and necessary actions.
Maintain current competency in provider quality regulations and standards.
Ability to work in a fast-paced, dynamic, and often ambiguous environment.

Nice To Haves

At least 5 years of clinical experience with direct patient care.
At least 5 years of experience with credentialing, peer review, or provider performance improvement.
Informatics and analytics experience with quality data from multiple disparate sources, including 834, 837, 278 EDI, and HIE HL7.

Responsibilities

Support organizational quality improvement efforts and promote a culture of quality improvement and performance.
Develop, approve, and update medical policies, procedures, and standards of care based on current evidence-based practices.
Oversee provider-facing activities related to HEDIS, CMS Stars, Covered CA performance, NCQA, and state and federal regulatory bodies, including provider performance measurement and reporting.
Oversee and review patient care delivery to ensure it meets quality standards and regulatory guidelines.
Direct peer review activities, including chairing the Credentialing and Peer Review Committee and managing the Potential Quality Issues process.
Maintain and enforce compliance with federal and state laws, accreditation processes and standards such as NCQA, and other regulatory requirements.
Guide quality assurance and performance improvement programs and participate in quality review committees.
Support population health management and practice transformation efforts to improve quality and value of care, control total costs of care, elevate member experience, and advance health equity.
Work with senior leadership to deploy standardized evidence-based medical best practices and clinical content and ensure adoption.
Lead and advise the Credentialing and Peer Review Committee, Provider Quality Review, and Clinical and Member Advisory Groups.
Liaise with Credentialing, Provider Network Management, and other provider-focused departments to establish and maintain best-practice provider quality operations.
Perform other duties as assigned.