Medical Director - Consultant - Health Plan of San Joaquin

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French Camp, CA, US

4 days ago Requisition

Salary Range: $150.00 To $150.00 Hourly

The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.

Health Plan of San Joaquin is currently hiring a consultant Medical Director. This is a remote position; must reside in California.

What You Will Be Doing:

Under limited supervision, the Medical Director consultant is responsible for providing clinical oversight of the Health Plan’s utilization, quality, pharmacy, and credentialing and health equity functions in a manner that ensures the delivery of quality, cost effective healthcare, supports organization objectives, and meets contractual, accreditation and regulatory requirements. The position supports the grievances and appeals team with clinical oversight of grievances and quality of care investigations and resolutions.

Work is varied and highly complex and requires a moderate to high degree of discretion and independent judgment.

Essential Functions:

• Provides clinical leadership for medical management functions; assists subordinate managers in resolving medical claims review, grievances, appeals, and other medical management issues.
• Works closely with the Deputy CMO (DCMO) to identify medical service issues that have an impact on plan benefits and their administration, develop action plans and monitor results.
• Identifies and analyzes and assists in identifying and analyzing care and quality issues and trends; makes recommendations based on findings; develops and implements agreed upon changes.
• Provides clinical expertise needed to effectively and efficiently resolve complex, controversial, and/or unique administrative circumstances.
• Conducts clinical reviews and makes UM decisions for prior, concurrent, and retro authorizations, and appeals; approves/denies or offers medical alternatives according to HPSJ’s medical review criteria for both Medi-Cal and Dual Eligible Special Needs Plan (DSNP) members.
• Conducts reviews of grievances and quality of care issues for both Medi-Cal and DSNP members : identifies opportunities for improvement and works with both internal and external stakeholders to improve care and services.
• Provides expertise and guidance for activities related to improving quality and health equity metrics.
• Establishes and maintains working relationships with providers, provider organizations and other stakeholders that supports contracting, provider relations, marketing and other organizational goals and objectives.
• Collaborates with leadership to ensure medical compliance with internal, regulatory and accreditation requirements.
• Provides medical expertise and direction for clinical policies, procedures, and programs.
• Serves on Quality Improvement & Health Equity Committee, Peer Review and Credentialing Committee, Grievance and Appeals Committee, Clinical Operations Committee and Physician Advisory Committees; serves on other committees as required.
• Represents HPSJ in a manner that promotes a positive image of HPSJ in the community.
• Assists with development of corporate and department budgets and metrics.

What You Bring:

Knowledge, Skills, Abilities and Competencies

Required

• In-depth knowledge of the principles and practices of managed care related to utilization management and/or case management and/or discharge planning.
• In-depth knowledge of the healthcare, economic or other issues affecting Medi-Cal and/or Medicare populations, providers and the underserved in San Joaquin and surrounding areas.
• Basic knowledge of managed healthcare as applied to government sponsored programs including Medicaid and SCHIP.
• Strong knowledge of and ability to identify, implement, monitor and analyze relevant metrics models, and implement effective interventions based on results.
• In-depth knowledge of standard contract components and contract language specific to healthcare.
• In-depth knowledge of audit, control and monitoring processes, and the ability to effectively implement and maintain them.
• Financial acumen:
  Interprets and applies understanding of key financial indicators to make better business decisions.
• Strong skills in budget development and management.
• Manages complexity:
  Makes sense of complex, high quantity, and sometimes contradictory information to…