Medical Director – Whole Child Program – Pediatrics
WCM Medical Director is responsible for providing clinical oversight for utilization, quality and case management functions for the Whole Child Model Program (WCMP) population. This oversight will ensure the delivery of quality, cost effective healthcare, supports WCM Program objectives and meets all regulatory requirements. Work is varied and highly complex and requires a moderate degree of discretion and independent judgment.
• Provides clinical leadership for medical management functions including utilization management and case management for WCM population in accordance with the appropriate clinical criteria. Participates in all complex case management team meetings related to WCP participants
• Reviews all deaths of enrollees
• Reviews all preauthorization denials and requests for high cost durable medical equipment
• Provides guidance to Peds WCMP team on Numbered Letters affecting CCS conditions, medications, medical procedures, etc.
• Review all air transport, kidney transplant and inpatient rehabilitation requests
• Provides medical direction on medical eligibility and medical benefits in accordance with State and County rules and regulations. Works with the Senior Medical Director regarding clinical program policies and procedures
• Provides medical consultation to the nurse case managers, Medical Therapy Program Units clinical staff
• Serves as the WCMP physician liaison with Special Care Centers
• Addresses WCMP due process and appeals related to medical eligibility and assists with writing responses to appeals and fair hearing requests
• Establishes and maintains working relationships with CCS providers, provider organizations and other stakeholders that supporting provider contracting/relations, marketing and other organizational goals and objectives. Works with Provider Services Department on the training of Providers on WCMP standards, policies and procedures including care coordination, medical home and family-centered care
• Participates in a system to resolve medically related grievances from Providers and/or clients and families
• Involvement with the Pediatric Clinical Advisory Board and Family Advisory Committee where appropriate
• Participates in quality activities related to the WCMP including reporting on performance measures