Kern Family Health Care, Bakersfield, California, United States of America
Job Description
Posted Friday, July 19, 2024 at 10:00 AM
We appreciate your interest in our organization and assure you that we are sincerely interested in your qualifications. A clear understanding of your background and work history will help us potentially place you in a position that meets your objectives and those of the organization. Qualified applicants are considered for positions without regard to race, color, religion, sex (including pregnancy, childbirth and breastfeeding, or any related medical conditions), national origin, ancestry, age, marital or veteran status, sexual orientation, gender identity, genetic information, gender expression, military status, or the presence of a non-job related medical condition or disability (mental or physical).
KHS reasonably expects to pay starting compensation for the position of Medical Director in the range of $256,809 – $333,853 annually. *This is an onsite position that will provide clinical oversight and leadership for the Medicare/DSNP program.
Our Mission.. Kern Health Systems is dedicated to improving the health status of our members through an integrated managed health care delivery system.
About the role
The Medical Director will provide clinical leadership and guidance in the development and measurement of the strategic approach to quality, performance improvement, and patient satisfaction, and safety. As determined by the plan Chief Medical Officer, the Medical Director assists in short- and long-range program planning, total quality management (quality improvement) and external relationships, as well as develops and implements systems and procedures for all medical components of health plan operations.
In collaboration with the Chief Medical Officer and others, the Medical Director creates and implements health plan medical policies and protocols. The Medical Director monitors provider network performance and reports all issues of clinical quality management to the Chief Medical Officer and Quality Improvement Committee. Additionally, he or she represents the health plan on various committees and routinely reports to the Board of Directors on credentialing and re-credentialing of network providers. The Medical Director provides medical oversight into the medical appropriateness and necessity of healthcare services provided to Plan members and is responsible for meeting medical cost and utilization performance targets.
Essential Duties and Responsibilities
Under direction of the Chief Medical Officer:
- Under the direction of the CMO provide clinical oversight and leadership for the Medicare/DSNP program.
- Participates in carrying out the organization's mission, goals, objectives, and continuous quality improvement of KHS;
- Provides clinical leadership to the clinical departments staff and works collaboratively with the directors of the other Departments of KHS to ensure compliance with the contractual and regulatory requirements;
- Provide clinical support and education to the network provider in support of standards of care and evidence-based medicine and use of clinical criteria in decision management;
- Represents KHS in the medical community and in general community public relations;
- Responsible for Review and identification of area for improvement and provide clinical leadership in the implementation of KHS Quality Improvement Plan and the Utilization Management Plan;
- Lead and/or attend and actively participate in meetings and committees as assigned by the CMO;
- Actively Participates as a member of the Health Services management team;
- Provide Clinical oversight and leadership for the Medicare program.
- Lead the DSNP Utilization Management (UM) Committee, to ensure compliance with all CMS requirements.
- Assist with the development and implementation of strategies to ensure appropriate, cost-effective, efficient care for Medicare products specifically DSNP.
- Act as physician leader for the Plan for all Medicare quality management functions: analyze information to develop interventions that improve quality of care and outcomes, with a focus on at risk performance (ex: STARS, State-based programs, VBC).
- Develop and deliver presentations for KHS Clinical staff on current topics relevant to Medicare.
- Provide expert consultation for Medicare compliance activities including audit activities and lead clinical oversight of delegated entities.
- Work with relevant business areas on plan polices and operations related to Medicare benefits and claims management.
- Perform Peer-to-Peer outreach functions in support of the Plan's Medicare Drug Management Program.
- Execute a comprehensive analysis and clinical evaluation of each case, enlisting specialty input as needed.
- Execute medical management decisions in a timely fashion meeting all regulatory requirements for all lines of business (Medicare) in terms of utilization management and appeal case reviews.
- Handle initial determinations, appeals and grievances within the scope of expertise as defined by KHS, Medicare, NCQA and other regulatory agencies.
- In conjunction with the Medical Director team, review and implement utilization management and medical policy, including recommendations for improvements to enhance efficiency.
- Partake in the assessment of new, emerging, and existing technologies to determine appropriateness of health plan coverage.
- Work in collaboration with UM and Care Management (CM) teams to understand utilization of services and develop and implement programs to address inappropriate utilization and readmissions.
- Support and uphold regulatory requirements, compliance, policies and contractual agreements, and address/mitigate risk.
- Work within the Plan and with network providers on value-based initiatives, quality, and provider satisfaction; supports providers to align performance with plan goals.
- Support the clinical, network, and operations staff to ensure end to end consistency of clinical policies, payment policies and claims payment.
- Serves as a member of KHS Committees or workgroups. Supports new market entry and implementations Foster collaborative relationships with customers and stakeholders.
- Provide leadership and oversight in a way that promotes a supportive, respectful environment.
- Develop effective relationships with leaders and staff in the Health Plan. Present ideas, updates, findings, reports, recommendations, data, and analysis to various audiences to build consensus on program initiatives Represents KHS at Administrative Law Judge hearings.
- Lead and/or attend and actively participate in meetings and committees as assigned by the CMO;
- Actively Participates as a member of the Health Services management team;
Knowledge & Skill Requirements
- Extensive knowledge of the use of MCG guidelines in clinical decision making;
- Knowledge of medical management systems and software to support clinical actives in Health services;
- Experience in population health management and use of data to design and implement clinical program;
- Experience at the different levels of Managed Healthcare delivery including but not limited to CMS and Medi-Cal requirement for Managed Care Organization;
- Experience working with different levels of staff in a matrix organization;
- Strong analytical, problem-solving skills with good negotiation skills;
- Very strong interpersonal skills, including the ability to establish and maintain effective working relationships with individual at all levels both inside and outside of KHS;
- Effective oral and written communication skills, including the ability to effectively explain complex information and document according to clinical standards;
- Demonstrated ability to commit to and facilitate an atmosphere of collaboration and teamwork;
- Ability to supervise and mentor staff, analyze situations independently and make appropriate decisions;
- Ability to prepare written reports and maintain accurate records in compliance with State and federal requirements for clinical documentation and privacy rules;
- Strong analytical, assessment and problem-solving skills with intermediate negotiation skills;
- Very strong interpersonal skills, including the ability to establish and maintain effective working relationships with individuals at all levels both inside and outside of KHS;
- Advanced computer skills that include MS Office products;
- Demonstrate ability to respect and maintain the confidentiality of all sensitive documents, records, discussions, and other information generated in connection with activities conducted in, or related to, patient healthcare, KHS business or employee information and make no disclosure of such information except as required in the conduct of business;
- Strong attention to detail; work accurately and at a reasonable rate of speed;
Employment Standards
Education:
- Licensed M.D. or D.O. in good standing in the state of California;
- Board certification in their area of specialty by the American Board of Medical Specialists (ABMS);
- MPH, MBA, or MHA Preferred;
- Certification by the American Board of Quality Assurance and Utilization Review Physicians or the American Board of Medical Management preferred;
- A current and unrestricted license in CA.
- Board Certified in an approved ABMS Medical Specialty. Excellent communication skills.
Experience:
- Minimum of five (5) years of established clinical experience. Knowledge of the managed care industry including Medicare, Medicaid and or Commercial products. Must be passionate about contributing to an organization focused on continuously improving consumer experiences Preferred Qualifications. Medical utilization management experience, working with health insurance organizations, hospitals and other healthcare providers, MSO, patient interaction, etc
- Minimum of three (3) years medical leadership experience in a managed care organization or clinical setting;
- History of successful clinical outcomes and ability to analyze data for quality improvement and outcomes;
Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine, and General Surgery clinical specialists.
Knowledge of
- Understand quality improvement cycle processes and outcome analysis. Expertise in healthcare delivery systems and quality performance improvement initiatives.
- Knowledge of Medicare/DSNP
- The ability to provide clinical oversight and leadership for the Medicare/DSNP program.
Other:
- Possession of valid California Driver’s License and proof of valid State required auto liability insurance. Travel up to 10 % required;
- May be requested on occasion to travel to conferences and meetings as an organization representative. Must be able to make arrangements to attend these as required;
- Good manual and finger dexterity is needed; up to 75 percent of working time may be spent using a computer keyboard;
- Vision, hearing, speaking must have good visual acuity and depth perception to operate the computer system; speaking and hearing are essential to the communication needs of the position;
We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis.
Kern Family Health Care, Bakersfield, California, United States of America
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