Senior Medical Director, Network Performance 26-41

PriMed Management Consulting•San Ramon, CA

20h•$272,000 - $353,000•Onsite

About The Position

Under the direction of the Chief Medical Officer, the Senior Medical Director is responsible for clinical oversight and management of network performance. The Senior Medical Director works in partnership with the CMO and the VP of Clinical Services to ensure sound and compliant utilization management practices, ensure regulatory compliance, and support key clinical functions of the Utilization Management, Care Management and Appeals and Grievances teams.  This key leader partners with the VP Clinical Services in the oversight of the inpatient and outpatient authorization review and denial process and is responsible for the training and mentoring of Physician Authorization Reviewers and Physician Advisors in the application and documentation of medical necessity criteria, the IRR process and response to audits. The Senior Medical Director of Network Performance collaborates with VP Population Health and may direct activities of the Regional Medical Directors to support organizational initiatives and to improve performance of individual practices. Support the advancement of the Clinically Integrated Network with recommendations on care guidelines, practice engagement and other priority areas. This leader is a key part of PriMed Hill Physicians’ Senior Leadership Team and will be in office/onsite two days a week. Key Areas of Focus: Provide support and leadership in developing and implementing UM Strategy and Program. Provide support and physician guidance on optimization of Care Management programs to improve outcomes for patients and value for plan partners. Review and make recommendations on workflow, staffing, training, and quality improvement opportunities in our authorization review processes. Partner with VP Population Health and team members to drive improvement on quality metrics through engagement of network practices. Develop and increase collaborative relationships with external partners and stakeholders evidenced by improved clinical performance metrics. Use of data analysis and reporting to track performance within full risk and partial risk agreements at the organizational and practice level and to identify improvement opportunities for network performance including member experience, access, appropriate care, site of service and potential cost savings. Work collaboratively with operational and support teams to identify and implement improvement initiatives. Support the work of the Utilization Management Committee, the Quality Improvement Committee, and others to include review of data, respond to committee inquiries, and ensure implementation of approved policies.

Requirements

5 years of post-residency experience in a recognized medical specialty, which must have included at least (3) years of managed care experience.
Experience working with clinical practice guidelines and evidenced based criteria sets.
Possesses strong knowledge of Managed Care principles, utilization and case management programs and has exposure to working with regulatory agencies.
Experience leading Quality Improvement efforts.
Knowledge of and experience with full and partial risk models in commercial, Medicare and Medi-Cal.
MD/DO degree from an accredited program, with an active, unrestricted California medical license.
Board certification.
A current CA license to practice without restriction.
3-5 years of supervisory/management/leadership experience in managed care setting.
Experience in delivery and implementation of Utilization Management and Care Management initiatives.

Nice To Haves

Preferred experience is in adult primary care, such as family practice or internal medicine.
Knowledge of CMS and Medicaid regulations preferred, Medical Director for an IPA, medical group, or HMO highly desirable.

Responsibilities

Provide clinical oversight of all PriMed Hill Physician Utilization Management (UM) and Medical Management functions.
Review of UM Program and support update and implementation of UM Strategy and Program.
Serve as a teacher and mentor to Physician Authorization Reviewers and Physician Advisors for their job functions as well as to team members of Care Management, Utilization Management, Appeals and Grievances and others.
Partner with VP Population Health and team members to drive improvement on quality metrics through engagement of network practices.
Support the advancement of the Clinically Integrated Network with recommendations on care guidelines, practice engagement and other priority areas.
Develop and increase collaborative relationships with external partners and stakeholders evidenced by improved clinical performance metrics.
Monitor network performance proactively to ensure high quality member/patient experience with the right level of care at the right time and appropriate site of care, optimizing in network care when possible and appropriate.
Identify areas of risk and opportunities to optimize utilization management.
Support workflows and processes for optimized Pre-admission authorization.
Review of Long-Term Care Services and Support including Skilled Nursing and Subacute care for quality and value.
Inpatient claims review to ensure appropriate levels of care and opportunities to increase in-network care.
Identify potential Clinical Quality Issues.
Support of Grievance resolution.
Model data-driven leadership, ensuring interventions are measured and evaluated for efficiency and impact.
Promote and further PriMed Hill Physicians culture and mission by fostering an environment where all staff are recognized, understood, appreciated, and embrace inclusion and belonging.