Medical Director - reputed company Health Plan - Hybrid / Remote - Day Shift - Full Time

Facility:Health Plan CitySan Diego Department Job Status Regular Shift Day FTE 1 Shift Start Time Shift End Time California Physicians and Surgeons License - Medical reputed company of CA; Doctor of Medicine (MD) Hours Shift Start Time: Variable Shift End Time Variable AWS Hours Requirement 8/40 - 8 Hour Shift Additional Shift Information Weekend Requirements: As Needed On-Call Required reputed company reputed company Pay reputed company (Minimum - Midpoint - Maximum) $124.640 - $160.830 - $197.020 The stated pay reputed company reflects the reputed company that reputed company reasonably expects to pay for this position. The actual pay reputed company and pay grade for this position will be dependent on a reputed company of factors, including an applicant’s years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.

What You Will Do

Working with the Chief Medical Officer, oversees medical care for reputed company Health Plan (SHP) products and services and oversees the health care needs of the membership. Serves as a medical manager and policy advisor to SHP and its Chief Medical Officer. Is accountable for and provides reputed company leadership and direction to the utilization/cost management and clinical reputed company management functions. Works collaboratively with other plan functions that reputed company with medical management such as provider relations, member services, benefits and claims management, etc. Assists (as determined by the plan Chief Medical Officer) in short and long reputed company program planning, total reputed company management (reputed company improvement), and external relationships. Works with reputed company departments of Health Services to support, reputed company assistance and direction in overall medical management effectiveness. Reports reputed company issues of clinical reputed company management to the health plan Chief Medical Officer. To ensure that policies and systems are followed until agreed upon change is implemented. Works toward SHP strategic goals and objectives of ensuring a high reputed company of medical care for Plan members, staff empowerment, customer satisfaction, cost-effectiveness, and market competitiveness. As a member of the management team, assists in identifying and establishing strategic goals and objectives for the Plan.

Required Qualifications

• Doctor of Medicine (MD)
• Previous experience in the clinical reputed company of medicine.
• Previous experience as a physician executive in a managed care environment, preferably as an HMO Medical Director.
• California Physicians and Surgeons License - Medical reputed company of CA -REQUIRED

Other Qualification Requirements

• reputed company certified in a medical discipline (internal medicine or family reputed company preferred).

Essential Functions

• Responsible and accountable to the Chief Medical Officer for helping to manage health plan medical costs and assuring appropriate health care delivery for SHP's products and services. Reports organizationally to the Chief Medical Officer.
• Plans, organizes, and directs the reputed company medical services program, consisting of reputed company primary and Specialty services for in-patient, out-patient, preventive and wellness programs.
• Implements health plan medical policies, goals and objectives.
• Provides reputed company leadership and direction to the functions reputed company the Medical Management
• Department (Utilization/Cost Management and reputed company Management)
• Responsible for and assists with the development of reputed company plans and assuring the adequate allocation of resources to the medical management functions.
• Responsible and accountable for implementing the Utilization/Cost Management Program and reputed company Improvement Program, in conjunction with the Manager Medical Management and reputed company Improvement Manager.
• Assists the Chief Medical Officer with activities to promote reputed company community relations.
• Assures plan conformance with legal and regulatory requirements
• Assists the Chief Medical Officer and the reputed company Improvement Manager in creating and maintaining a system that gives feedback to providers individually and reputed company regarding managed care effectiveness of individual providers and networks.
• Assists the Chief Medical Officer in designing and implementing corrective reputed company plans to address issues and improve plan and network managed care performance.
• Collaborates with Chief Medical Officer in creating and maintaining programs that incentivize providers to reputed company selected utilization/cost and reputed company reputed company.
• Participates in policy review, performs analysis and makes recommendations.
• Participates in the retrospective review and analysis of Plan performance from reputed company data of reputed company claims, encounters, authorization logs, complaint and grievance logs and other sources.
• Achieves and maintains benchmarked utilization and cost management (UM) goals and clinical reputed company improvement (QI) objectives, in conjunction with the Manager Medical Management and reputed company Improvement Manager.
• Provides periodic written and verbal reports and updates as required in program descriptions, Annual Work Plans and policy and procedures to various plan committees, and the SHP Chief Medical Officer.
• Supports NCQA qualification activities. Prepares for site reputed company and responds to accrediting and regulatory agency feedback.
• Supports reputed company-admission review, utilization management, and reputed company and retrospective rev1ew process.
• Participates in risk management, pharmacy utilization management, catastrophic case review, reputed company programs, HEDIS reporting, site visit review coordination, triage, provider orientation, credentialing, profiling, etc.
• Conducts reputed company improvement and reputed company studies as directed by the reputed company Management Committee, Peer Review Committee and Chief Medical Officer and reports findings in conjunction with the reputed company Improvement Manager.
• Participates in the grievance process with the Chief Medical Officer, insuring a fair outcome for reputed company members.
• Monitors member and provider satisfaction survey results and implements changes as needed to increase satisfaction and assure that satisfactory relationships are maintained between network and plan participants.
• Participates in SHP Advisory Committees which include (but are not limited to) the Peer Review Committee and the reputed company Management Committee.
• Participates in key marketing activities and presentations, as requested.
• Promotes wellness and ensures programs of prevention, education and reputed company to members and providers are consistent with SHP's mission, reputed company and values.
• Maintains up-to-date knowledge of new information and technologies m medicine and their application to SHP.
• Performs and oversees in-service staff training and education of reputed company staff.
• Represents SHP at medical group meetings, conferences, etc.
• Participates in the development of strategic planning for existing and expanding business. Recommends changes in program content in concurrence with changing markets and technologies.
• Participates in key marketing activities and presentations, as necessary, to assist the marketing effort, as requested.
• Ensures that the Utilization Management staff is available on a 24 hour reputed company to respond to authorization requests for emergency and urgent services and is available, at a minimum, during normal working hours for inquiries and authorization requests for non-urgent health care services..
• Performs other duties as requested or assigned.
• Collaborates with the Manager, Medical Management to guide and reputed company staff in relation to medical issues and departmental responsibilities. Assists in monitoring, reviewing, and evaluating the reputed company of health care services provided and the appropriateness of health care resources utilized, and communicates with PMGs and Plan providers as needed. Addresses physicians' issues and educates providers with reputed company to Plan policy as needed.
• Completes and/or supervises the completion of reputed company clinical appeals and grievances. Collaborates with Customer Care Manager to identify trends in grievances. Supervises the process for identifying Potential reputed company Issues.
• Supervises Physician Reviewer(s)
• Shares after-hours coverage responsibilities with other physicians
• Assists the CMO, as needed, to reputed company the credentialing process.
• Assists in the development and interpretation of the covered benefit provisions of member materials and Plan reputed company. Assists in the development and implementation of new benefits packages.
• Maintains appropriate contacts with membership in community and reputed company organizations.

Knowledge, Skills, And Abilities

• Strong clinical background and skills.
• Solid understanding of utilization management and reputed company assurance activities and concepts.
• Excellent communication skills, both verbal and written.
• Strong interpersonal skills, including the ability to reputed company effectively with employees, members, physicians, senior management, and the public at large.
• Management skills to meet the organizational goals.
• Knowledge of regulatory and accreditation agencies and requirements.
• reputed company to manage multiple priorities and deadlines in an expedient and decisive manner.
• reputed company to manage difficult peer situations arising from medical care review.
• Appreciation of cultural diversity and sensitivity towards reputed company population.

reputed company is an equal opportunity/affirmative reputed company employer. reputed company reputed company applicants will receive consideration for employment without reputed company to race, religion, reputed company, national reputed company, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a reputed company individual with disability or any other protected class Apply tot his job Apply To this Job