Under direction, the Valley Health Plan (VHP) Medical Director is responsible for providing medical leadership and direction to the case management, clinical quality management, and strategic development functions. This classification reports to the VHP Chief Medical Officer (CMO) and assists the VHP CMO and collaborates with other plan functions that interface with medical management. This Physician Executive is Unclassified (at-will). There is no probationary period.
About the Position
Valley Health Plan (VHP) is seeking a Medical Director who will be responsible for providing medical leadership and direction to the case management, clinical quality management, and strategic development functions. This position works closely with the Chief Medical Officer to create and maintain programs, design and implement corrective action plans, participate in policy creation and review, perform analysis, engage internal and external stakeholders, and work collaboratively with other plan functions that interface with medical management.
Minimum Requirements:
Must be a licensed Physician in California. Candidates must have at least (5) five years of clinical experience and at least one (1) year of experience in medical supervision and management in a managed care environment, physician group management, or integrated health care system management.
Key Responsibilities:
- Serves as a VHP Medical Director, overseeing the quality of care and the continual improvement of services and medical outcomes;
- Serves as a medical manager and policy advisor to the CMO;
- Ensures the minimum regulatory standards for turnaround-times are met, continues the innovation of external-facing programs, and builds internal processes and efficiencies to maximize plan productivity and achieve ongoing cost-savings;
- Participates in utilization review as it pertains to prior authorization, concurrent review, and post-service requests, as well as appeals and grievance decisions and correspondence;
- Oversees the management of utilization for all VHP members and delegated membership;
- Works collaboratively with other plan functions that interface with medical management, such as provider relations, member services, appeals and grievances, and claims management;
- Utilizes policies, established guidelines (e.g., Medi-Cal, Milliman Care Guidelines, Apollo) to perform authorization and concurrent review to determine medical necessity and appropriateness of services;
- Manages a system that gives feedback to providers individually and collectively regarding quality-of-care outcomes, managed care effectiveness of individual providers and networks, and network adequacy;
- Designs and implements corrective action plans to address issues and improve plan and network managed care performance;
- Creates and maintains programs that incentivize providers to achieve selected utilization/cost and quality outcomes in conjunction with the QM and Strategic Improvement Team;
- Engages internal and external partners in medical management, incentives, processes, and development;
- Participates in short and long-range program planning, quality improvement, and external relationships;
- Ensures care is consistent with VHP's standards of quality;
- Coordinates with CMO to provide daily support and appropriate direction to staff on issues pertaining to Utilization Management (UM), Case Management, Quality Management (QM), and other Medical Management Divisions;
- Participates in policy creation and review, performs analysis, and makes recommendations for programs and coverage based on evidence and data;
- Participates in the retrospective review and analysis of plan performance from summary data of paid claims, encounters, authorization reports, grievances/appeals/disputes, and other sources;
- Meets regularly with CMO and advises on the development of goals and objectives, work plans, and priorities;
- Monitors the daily UM authorizations and systems (out of network requests, durable medical equipment, concurrent inpatient status, VHP non-formulary drug requests) and related UM system issues for compliance, utilization of medical necessity criteria, and quality of care;
- Oversees the quality of care and continual improvement of services/outcomes;
- Collaborates with the QM, Strategic Improvement Department to improve the Healthcare Effectiveness Data and Information Set (HEDIS) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) scores;
- Participates in chairs meetings, as needed and as determined by CMO;
- May be assigned Disaster Service Worker duties;
- Performs other related duties, as assigned.
Employment Standards:
Considerable education, training and experience which demonstrates possession and application of the following knowledge and abilities. Must be a licensed Physician in California. The successful candidate will have at least (5) five years’ of clinical experience and at least one (1) year of experience in medical supervision and management in a managed care environment, physician group management or integrated health care system management.
Knowledge of:
- Managed care principles, medical group management, hospital and health plan operations, California Health and Safety Codes (Title 22 and 28, HEDIS, NCQA standards, Medi-Cal, Medicare, and Utilization Management guidelines such as Milliman and InterQual);
- Laws/regulations governing California Health Services providers, JCAHO and other regulatory entities;
- Principles and practices of modern medicine;
- Advanced management practices and organizational dynamic principles;
- Quality assurance as it applies to medical services;
- Program management and health care administration;
- Lean process improvement and quality improvement processes;
- Principles and practices of health care administration, organization, budget, management analysis, supervision, personnel management, employee relations, information systems applications and organizational development;
- Demographic and client service and utilization data for decision-making, program design and the development and evaluation of program and system metrics;
- Financial and administrative problems common to health care operations;
- Cultural values and practices of the diverse communities served by the department.
Ability to:
- Respond creatively to issues and advances in systems and methods for the practice of primary, specialty and tertiary care;
- Develop and implement effective health care policy, quality monitoring, medical appropriateness, and utilization of health care services;
- Respond creatively to a changing healthcare marketplace and improve patient access, the quality of care, and patient experience in a market-competitive environment;
- Demonstrate excellent judgment skills and work in a continuous improvement environment;
- Consistently and positively communicate and collaborate with colleagues, supervisors, and customers, both internal and external;
- Efficiently and independently plan time, meet deadlines, initiate and follow through on tasks;
- Listen respectfully and carefully, demonstrating flexibility in working with others;
- Demonstrate sensitivity to people of different cultures and work effectively with others;
- Meet attendance standards and use timekeeping system accurately and consistently;
- Work proficiently with common professional office software;
- Demonstrate leadership and teamwork with peers, internal stakeholders and external customers that inspires alignment and partnership on a shared vision or strategy;
- Rapidly adopt and utilize new digital technology and other resources with medical customers and record medical interactions.
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