Senior Medical Director - 2024-1124-2367

PacificSource • Boise, ID, United States • $200k - $250k / year • 2w ago

PacificSource Senior Medical Director - 2024-1124-2367 Boise, Idaho

This job was posted by IdahoWorks. For more information, please see: Job Posting

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PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.

Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected, and responded to in ways that fully develop and utilize each person's talents and strengths.

Responsibilities:

Lead improvement in clinical development strategies and execution of clinical programs including implementation of the strategic plan through strategic cascades and metrics.
Oversee operational activities of the medical directors and lead a clinical team.
Interface and collaborate with health services project management and leadership within PacificSource to carry out initiatives of the strategic plan and CMO.
Engage with the provider community in support of PacificSource's strategic and operational goals.
Lead clinical utilization review efforts (e.g., lengths of stay, appropriateness of service, intensity of service, medical necessity).
Oversee pre-authorizations review, claims, and other cases involving pre- or post-service requests for coverage.
Provide expertise and medical interpretation regarding claims adjudication, underwriting, contract language, disputes and appeals, policy drafts, and care management issues.
Establish guidelines, policies, criteria, and procedures for review related to clinical practices, claims, care coordination, reimbursement, provider credentialing, and quality management.
Manage systems of care with providers for appropriate care and case management.
Provide clinical and operational expertise for physical and behavioral health care, quality, case management, risk, network, and utilization management.
Lead Cost Containment Committees and address trends impacting global budget in line with Triple Aim goals.
Manage internal operations related to the cost of care and cost functions with defined Provider Partners.
Manage data and analytics to deliver actionable insights to provider partners.
Provide leadership in decision making for inclusion and integration of new clinical services within Health Services.
Apply process improvement techniques to enhance operational efficiency and effectiveness.
Collaborate with committees as needed, preparing agendas and following through on actions.
Review and manage appeals and grievances, assisting in preparation for external review.
Interface with the Oregon Health Authority to influence and implement Oregon Health Plan clinical policy.
Develop annual department budgets and monitor spending versus planned budget.
Responsible for hiring, staff development, coaching, performance reviews, corrective actions, and termination.

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