Senior Medical Director - Policy & Outcomes

Inland Empire Health Plan-posted 2 months ago
$280,841 - $393,182/Yr
Full-time • Senior
Rancho Cucamonga, CA
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Find joy in serving others with IEHP! We welcome you to join us in 'healing and inspiring the human spirit' and to pivot from a 'job' opportunity to an authentic experience! Reporting to the Vice President of Health Services, the Senior Medical Director Policy & Outcomes (Sr. Medical Director - P&O) is responsible for the strategic oversight of IEHP Medical Policies and clinical leadership around member health outcomes. The Sr. Medical Director - P&O oversees the day-to-day operations as it relates to developing, executing, leading and updating guidelines, policies, clinical pathways, and communications enabling effective health outcomes, as well as effective health plan performance as per DHCS, DMHC, CMS, and CCA clinical requirements. This leader serves as the accountable medical leader for clinical activities related to key activities including quality management, grievance and appeals, delegation oversight, and population health management. The Sr. Medical Director - P&O also works in partnership with the appropriate cross functional departments to monitor the impact of policy outcomes through regular reporting, metrics, initiatives, and other improvement activities. This position is responsible for leading regulatory audits for all its relevant domains.

  • Lead the development and execution of creating and/or updating medical policies and procedures to align with health plan regulatory requirements.
  • Ensure guidelines and clinical pathways are updated with best practices, along with appropriate downstream connections to utilization management, population health, and other compliance and regulatory activities.
  • Lead, develop and implement clinical programs and medical policies to align with IEHP’s strategic priorities in order to improve member safety, quality of care and outcomes.
  • Lead clinically, through strong partnerships with other departments for activities related to member outcomes, quality improvement, grievance and appeals, and network corrective action plans.
  • Develop and increase collaborative relationships with internal departments.
  • Assure interdepartmental collaboration and communication with key business departments, including, but not limited to, compliance, member experience, provider relations, and claims.
  • Serve as a liaison with providers, county public health partners and oversight agencies as assigned.
  • Monitor network performance proactively to ensure adherence to policy standards.
  • Develop and implement appropriate internal initiatives to address any issues impacting member outcomes.
  • Co-leadership with the Sr. Medical Director of Health Services to advance IEHP’s Mission, Vision and Values.
  • Manage medical directors, as well physician reviewers, working in the domains of policy, outcomes, quality management and clinical guideline development.
  • Provide clinical direction to the Health Service team and act as a resource to all IEHP departments responsible for providing or coordinating clinical services to IEHP members.
  • Direct, implement, and/or enhance medical policy, internal policies, and job aids as it relates to member safety and quality management activities.
  • Ensure medical decisions are rendered by qualified medical personnel, unhindered by fiscal or administrative management.
  • Direct clinical and workflow training for medical directors and physician reviewers within their oversight.
  • Ensure medical personnel of the Plan and its delegates follow IEHP policies, protocols and rules of conduct consistent with the values of IEHP.
  • Identify gaps in policies or activities relating to member outcomes and implement strategic, effective solutions.
  • Serve as a primary point of contact for clinical, quality and performance issues for medical directors at delegated IPAs, as well as for providers in the IEHP direct network.
  • Support other departments as needed to ensure timely completion of member grievances and appeals as required for regulatory compliance.
  • Provide clinical leadership, support and/or guidance in areas such as pre-admission authorization, prospective, concurrent and retrospective review, inpatient case review, inpatient claims reviews, utilization review, member case management, provider incentive programs, credentialing, peer review, and NCQA Accreditation.
  • Review State mandated benefits to ensure IEHP is in full compliance through its providers.
  • Perform any other duties as required to ensure Health Plan operations and department business needs are successful.
  • Seven (7) years of post-residency experience in a recognized medical specialty or practice, which must have included at least (3) years of medical administrative experience required.
  • Minimum of five (5) years of managed care or health plan leadership experience with proven track record of leading high performing physician teams.
  • Experience working with clinical practice guidelines and evidenced based criteria sets.
  • Has exposure to working with regulatory agencies.
  • Medical Director for an IPA, medical group, or CA HMO highly desirable.
  • Medical specialty/practice experience preferably in the state of California.
  • Doctorate of Medicine from an accredited institution required.
  • Certification by one (1) of the American Specialty Boards required.
  • Completion of an accredited residency program required.
  • Possession of an active, unrestricted, and unencumbered Physician’s and Surgeon’s Certificate issued by the State of California required.
  • Valid California Driver’s License preferred.
  • Familiarity with local healthcare organizations and/or local practice experience is preferred.
  • Highly Organized, Effective Communication Skills, Microcomputer applications such as Microsoft Word, Excel, and Access.
  • Proven execution skills.
  • Assertive communicator.
  • Demonstrate effective leadership of other physicians and clinical staff.
  • A track record of leading with accountability is required.
  • Competitive salary.
  • Hybrid schedule.
  • State of the art fitness center on-site.
  • Medical Insurance with Dental and Vision.
  • Life, short-term, and long-term disability options.
  • Career advancement opportunities and professional development.
  • Wellness programs that promote a healthy work-life balance.
  • Flexible Spending Account – Health Care/Childcare.
  • CalPERS retirement.
  • 457(b) option with a contribution match.
  • Paid life insurance for employees.
  • Pet care insurance.
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