Location: Must reside within reasonable driving distance from facility. Hybrid role with mandatory onsite (potentially 5 days a week) with presence in office and in our community, as needed.
French Camp Office
HPSJ/MVHP Headquarters
7751 South Manthey Road
French Camp, CA 95231-9802
Summary
Under administrative direction the CMO is responsible for leading efforts that will provide innovative solutions that support quality healthcare, promote personal accountability for health and wellness, and offer superior service and partnerships to the constituents served by HPSJ. Oversees Medical Management departments including strategic and regulatory initiatives, clinical analytics, pharmacy, and medical directors. Will be responsible for implementing all Medical Management aspects of Medicare. Work is varied and highly complex and requires a high degree of discretion and independent judgment. Will collaborate with the CMO to ensure regulatory compliance and quality care for members through all Medical Management activities.
Supervises
Pharmacy, Clinical Analytics, Strategic Initiatives, and Medical Director
Essential Functions
- Assists in the identification, planning and execution of strategies that drive and support corporate objectives, ensures compliance with the DHCS, DMHC and CMS regulatory requirements and NCQA accreditation requirements for health plan and health equity accreditation.
- Develops and oversees the implementation of medical policy.
- Ensures that medical decisions are rendered by qualified medical personnel and are not influenced by fiscal or administrative management considerations.
- Ensures consistent application of medical criteria to utilization management decision making.
- Ensures that medical care provided meets acceptable medical care standards.
- Ensures that medical protocols and rules of conduct for HPSJ medical personnel are followed.
- Identifies, and oversees the development of quality and utilization management activities that meet the needs of HPSJ providers, members, and regulators.
- Participates in the development and implementation of HPSJ grievance procedures.
- Manages medical utilization and quality healthcare through application of recognized medical and pharmaceutical guidelines and in collaboration with internal and external stakeholders.
- Oversees the development and management of department budgets.
- Oversees accreditation and compliance regulatory requirements within medical management are met.
- Identifies medical delivery system quality issues; develops and oversees implementation of corrective action plans.
- Collaborates with network providers and the provider community in a manner that engenders positive relationships, provider support and network stability.
- Advises on complex, controversial and/or unique claims that are outside the realm of medical policy.
- Ensures that effective collaborative work and problem-solving routines are maintained between assigned departments, and other internal and external stakeholders.
- Assists medical directors and reporting directors and teams in resolving medical and pharmacy Utilization and claims reviews, grievances, appeals, and other medical management issues as needed.
- Works closely with the CMO 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.
- 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 and reviews grievances and potential quality of care cases to ensure appropriate resolution as needed.
- Works closely with CMO to oversee accreditation and compliance activities to ensure agreed upon and mandated standards are met.
- Oversees all aspects of Medicare DSNP implementation for all medical management functions and collaborates with other areas as needed.
- 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.
- Ensures the identification, preparation, and maintenance of appropriate analytics and required data, records, and reports.
- Serves on and chairs as needed the Quality Improvement & Health Equity Committee, The Pharmacy & Therapeutics Committee, Quality Improvement and Health Equity Committee Operations Committee, Clinical Operations Committee, Grievance Committee, Peer Review and Credentialing Committee and 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.
- Promotes and maintains and ensures that direct reports promote and maintain an environment that supports HPSJ’s strategy, vision, mission, and values.
- Hires, develops, and retains, and ensures that line managers hire, develop, and retain competent staff.
Education and Experience
Required
- MD degree from an accredited medical school.
- Satisfactory completion of an American Council of Graduate Medical Education accredited residency program; and
- At least ten years clinical experience in the practice of medicine in fields related to a managed care setting; and
- At least five years clinical experience in the practice of medicine with Medi-Cal and/or Medicare populations; or
- Equivalent combination of education and experience.
- Eligible to participate in Medicare, Medicaid and/or other federal health care programs.
- Possess a National Provider Identifier (NPI); and
- At least five years supervisory experience in a Managed Care setting including Medicaid & Medicare experience.
- Equivalent combination of experience.
Preferred
- Experience as a senior leader in a Managed Care setting especially with Medicaid and Medicare lines of business.
Licenses, Certifications
Required
- Unrestricted license to practice medicine in the State of California, issued by the State Board of Medical Examiners, which meets the Health Plan’s credentialing and re-credentialing requirements.
- Board Certification in a chosen specialty.
- Valid California driver license and reliable transportation or, the ability to obtain transportation on demand in the counties served by HPSJ if prohibited from getting a driver license due to a medically documented disability.
Knowledge, Skills, Abilities and Competencies
Required
- Strong knowledge of and ability to identify, implement, monitor, and analyze relevant metrics models, and implement effective quality interventions based on results.
- 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, Stanislaus Counties, Eldorado & Alpine counties, and surrounding areas and in any areas of expansion of HPSJ’s service area.
- Basic knowledge of managed healthcare as applied to government sponsored programs including Medicaid and/or Medicare.
- 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.
- Develops strong relationships with network providers to ensure compliance with and commitment to Quality and Health Equity with regulators to be seen as a trusted partner.
- Strong skills in budget development and management.
- Manages complexity: Makes sense of complex, high quantity, and sometimes contradictory information to effectively solve problems.
- Decision quality: Makes good and timely decisions that keep the organization moving forward.
- Strategic mindset: Sees ahead to future possibilities and translates them into breakthrough strategies.
- Ability to execute and monitor relevant strategic and business plans.
- Resourcefulness: Secures and deploys resources effectively and efficiently; organizes people and resources to solve problems and identify opportunities.
- Plans and aligns: Plans and prioritizes work for self and others to meet commitments aligned with organization goals.
- Ensures accountability: Holds self and others accountable to meet commitments.
- Drives results: Consistently achieves results, even under tough circumstances.
- Strong collaboration skills with demonstrated ability to create and foster a collaborative work environment, maintain effective, high-performance teams, and organize people and resources to solve problems and identify business opportunities.
- Very strong interpersonal skills, with the ability to establish and maintain effective working relationships with individuals at all levels inside and outside of HPSJ.
- Very strong oral and written communication skills, with the ability to communicate professionally, effectively, and persuasively to diverse individuals and groups inside and outside of HPSJ.
- Strong presentation skills, including the ability to tailor presentations to a specific audience, and address and interact with large groups.
- Builds networks: Effectively builds formal and informal relationship networks inside and outside of the organization.
- Organizational savvy: Maneuvers comfortably through complex policy, process and people-related organizational dynamics.
- Persuades: Uses compelling arguments to gain the support and commitment of others.
- Manages ambiguity: Operates effectively, even when things are not certain, or the way forward is not clear.
- Manages projects and deliverables on time and on budget.
- Promotes and maintains and ensures that direct reports promote and maintain an environment that supports HPSJ’s strategy, vision, mission, and values.
- Ability to speak and be understood in English.
- Ability to handle confidential information with appropriate discretion.
Preferred
- In-depth knowledge of Medicaid and Medicare.
What You Will Get:
HPSJ Perks:
- Competitive salary
- Robust and affordable health/dental/vision with choices in providers
- Generous paid time off (starting at 3 weeks of PTO, 4 paid floating holidays including employee’s birthday, and 9 paid holidays)
- CalPERS retirement pension program, automatic employer-paid retirements contributions, in addition to voluntary defined contribution plan
- Two flexible spending accounts (FSAs)
- Employer-Paid Term Life and AD&D Insurance
- Employer-Paid Disability Insurance
- Employer-Paid Life Assistance Program
- Health Advocacy
- Supplemental medical, legal, identity theft protection
- Access to exclusive discount mall
- Education and training reimbursement in addition to employer-paid elective learning courses.
- A chance to work for an organization that is mission-driven – our members and community are at the core of everything we do.
- A shorter commute – if you’re commuting from the Central Valley to the Bay Area.
- Visibility and variety – you have a chance to work with people at all levels of the organization, and work on diverse projects.
We are an equal opportunity employer and diversity is one of our core values. We believe that differences including race, ethnicity, gender, sexual orientation and other characteristics, will help us create a strong organization that is sensitive to the needs of those we serve. Employment decisions are made on the basis of qualifications and merit.
HPSJ provides equal employment opportunities to employees and applicants for employment and prohibits discrimination based on color, race, gender (including gender identity and gender expression), religion (including religious dress and grooming practices), marital status, registered domestic partner status, age, national origin (including language use) or ancestry, physical or mental disability, medical condition (including cancer and genetic characteristics), sex (including pregnancy, childbirth, breastfeeding or related medical condition), genetic information, sexual orientation, military or veteran status, political affiliation or any other characteristic made unlawful by applicable Federal, State or local laws. It also prohibits unlawful discrimination based on the perception that anyone has these characteristics, or is associated with anyone who has or is perceived to have these characteristics.
Important Notice: This job description is not a contract between HPSJ and the employee performing the job. The duties listed in the job description may be changed at the discretion of HPSJ, and HPSJ may request the employee to perform duties that are not listed on the job description.
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