Medical Director

The Medical Director is responsible for providing clinical oversight for utilization, quality, care management and credentialing functions in a manner that ensures the delivery of quality, cost effective healthcare, supports organization objectives, and meets contractual and regulatory requirements. Work is varied and highly complex, and requires a moderate high degree of discretion and independent judgment. This position will focus on CenCal Health’s adult members and their service needs.

• Provides clinical leadership for medical management functions; assists subordinate managers in resolving medical claims review, grievances, appeals,
and other medical management issues
• Works closely with the CMO and other medical directors to identify medical service issues that have an impact on plan benefits and their administration,
develop action plans and monitor results
• Identifies, analyzes, and assists in identifying quality issues and trends; makes recommendations based on findings; develops and implements agreed
upon changes
• Provides clinical expertise needed to effectively and efficiently resolve complex, controversial and/or unique administrative circumstances. This includes
working with internal and external groups
• Conducts clinical reviews and makes UM decisions for prior, concurrent (hospital/ skilled nursing facility) and retro authorizations, and appeals;
approves/denies or offers medical alternatives according to CenCal Health medical review criteria; willingness to outreach to providers by phone and in
person as needed; develops UM policies and procedures in coordination with Health Services staff
• Works collaboratively with the Pharmacy team on clinical appropriateness of medication utilization
• Establishes and maintains working relationships with providers, provider organizations and other stakeholders that support contracting, provider relations,
marketing and other organizational goals and objectives
• Dedicated to process improvement and organizational efficiencies
• Clinical oversight and development of care management strategies and opportunities
• May support population health activities
• No current direct reports, the position may supervisor other Health Services staff in the future
• May participate in committee assignments such as Credentialing, Peer Review, Pharmacy & Therapeutics, and/or Quality Improvement
• Other duties as assigned

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