Senior Medical Director

Colorado Access•Denver, CO

7d•Hybrid

About The Position

Colorado Access is a Colorado-based company dedicated to improving the health of the state by serving individuals, families, and children enrolled in Child Health Plan Plus (CHP+) and Health First Colorado (Colorado's Medicaid Program). The organization focuses on driving improvements in quality, member experience, outcomes, and cost. It is a mission-driven organization with a vision and values that support its work. Colorado Access offers a work/life balance with benefits such as PTO, floating holidays, company-paid holidays, a hybrid work environment, an Employee Assistance Program, and a 401K. The company emphasizes making an impact by serving underserved and vulnerable populations through access to quality and affordable healthcare. Professional development is supported through tuition reimbursement, leadership training, promotion opportunities, performance evaluations, employee recognition, and a language pay stipend.

Requirements

Doctor of Medicine or Osteopathy with Board Certification, preferably in a primary care specialty or other relevant certification.
Minimum of five years in healthcare.
Minimum of two years of supervisory/leadership experience.
Experience in utilization management, medical necessity review, complex case management, population health, quality improvement, or managed care clinical operations required.
Current medical licensing in the State of Colorado.
Board certification.
A valid driver's license and proof of current auto insurance will be required for any position requiring driving.

Nice To Haves

Additional education such as Master’s Degree in healthcare related field is highly preferred.
Experience using clinical, utilization, quality, cost, and population health data to guide decision-making and evaluate program outcomes preferred.
Experience with clinical decision-support tools, predictive analytics, automation, artificial intelligence governance, or digital health initiatives preferred.
Bilingual communication skills in English and Spanish are preferred.

Responsibilities

Provides enterprise-wide physician leadership across clinical programs and teams.
Strengthens physician oversight of utilization management operations and clinical decision-making.
Partners with Population Health, Care Management, and Behavioral Health to provide clinical guidance.
Partners with Information Technology to provide clinical governance for artificial intelligence, technology, and automation affecting care and utilization management.
Serves as a clinical advisor to multidisciplinary teams requiring physician expertise.
Exercises independent judgment and escalates significant clinical or organizational risks as appropriate.
Leads organizational change and transformation while building trust and strong cross-functional relationships.
Builds high-performing teams through clear vision, leadership, goals, and performance measures.
Leads cross-functional projects and continuous improvement initiatives across multiple departments.
Oversees the development and implementation of departmental policies and procedures to ensure compliance with federal, state, local, and company requirements.
Establishes, monitors, and applies criteria to ensure health care utilization meets member needs, aligns with community standards of care, and supports the efficient and appropriate use of health care resources.
Oversee medical necessity determinations and clinical appeals of denied medical authorizations.
Provides internal consultation and guidance regarding referrals, denials, appeals, and clinical process issues.
Serves on the Credentials Committee may serve as chair and oversee the clinical aspects of the credentialing program.
Participates in the Pharmacy and Therapeutics Committee and oversees automated drug-management review processes and their connection to appeals.
Participates in provider and peer education related to medical management.
Provides clinical leadership for complex case management programs, including care models for members with complex medical, behavioral health, social, and functional needs.
Advises and partners with the Population Health department.
Uses clinical, utilization, quality, cost, and population health data to identify trends, evaluate program performance, inform interventions, and support continuous improvement.
Provides clinical guidance on predictive analytics, risk stratification, and other data-informed tools supporting utilization management, care management, quality improvement, and population health initiatives.
Supports the governance, evaluation, and responsible use of artificial intelligence, automation, and clinical decision-support tools to promote transparency, fairness, accuracy, privacy, clinical validity, and compliance.
Collaborates with operational and technology leaders to evaluate workflow optimization, automation, and data-driven decision support while maintaining appropriate medical oversight and accountability.
Provides strategic direction and oversees the management and maintenance of multiple department deliverables striving for operational excellence (productivity, quality, SLAs, customer experience of services provided, etc.).
Builds high performing teams with vision, leadership, goals and metrics.
Serves as a role model for team members; takes action and inspires team members to embrace and implement culture initiatives.
Provides awareness to department leaders and staff how their work impacts other departments, programs and the enterprise.
Encourages collaboration and holds team members accountable for achieving outstanding results.
Responsible for all management functions including: hiring, training, planning and directing work, coaching and staff development, managing and evaluating performance, recognizing and rewarding employees, corrective action procedures and practices, addressing complaints and resolving problems.
Develops and manages multiple department budgets.
Works closely with Directors across the organization to make tactical and operational decisions that advance company strategies and goals and collaborates to deliver on company-wide deliverables/requirements.
Oversees/leads projects and continuous improvement initiatives across multiple departments and/or cross-functional teams.
Oversees the development and implementation of multiple department policies and procedures to ensure compliance with federal, state, local and company policies, rules and regulations.