Senior Medical Director

The Gold Coast Health Plan (GCHP) Senior Medical Director supports the GCHP mission to improve the health of members through the provision of utilization management (UM), care management (CM), and disease management (DM) services. The Senior Medical Director oversees the development, implementation and effectiveness of UM, CM, and DM programs which meet regulatory guidelines; collaborates with leadership team on the effective medical cost and utilization performance of the health plan; and assists with the development and deployment of strategies for effective medical cost and quality of care management.

ESSENTIAL FUNCTIONS

Reasonable Accommodations Statement

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

Essential Functions Statement(s)

Under the direction of the Chief Medical Officer (CMO) and in collaboration with departmental Directors, the Senior Medical Director will be responsible for:

Utilization Management:

  • Consistent use of evidence-based guidelines to ensure right care. Development and adoption of additional guidelines as needed.
  • Measurement – development and reporting of utilization metrics and benchmarks.
  • Supervision of reviewing physicians.
  • Guidance and consultation to UM nurses.
  • Clinical aspects of member and provider grievance and appeal processing and decision-making.
  • Clinical aspects of Potential Quality Investigations (PQI) including analysis and reporting of trends.
  • Surveillance and determination of Provider Preventable Conditions (PPC).
  • Evaluate provider or member clinical appeals and refer to an appropriate 2nd reviewer when appropriate.
  • Coordination of peer-review organizations for specialty review UM and Appeals cases.
  • Collaborate with providers to ensure appropriate care for Plan Members.

Care Management:

  • Coordination of care and facilitation of collaboration with external stakeholders in the provision of coordinated care.
  • Provide oversight and clinical direction to the Care Management team, including guidance and consultation to CM nurses.
  • Direct and implement medical policy for inpatient and outpatient Care Management functions.

Population Health:

  • Collaborate with teams on population-based approach to clinical and quality management of identified chronic conditions.
  • Provide direction and oversight for design and implementation of population health strategy and high-impact member programs.
  • Utilize quality improvement and data analytics tools to develop processes that promote continuous improvement in outcomes and workflows.
  • Manage population health metrics across clinical operations for more reliable, equitable, and high-quality care.

Committee Participation:

  • Chair Utilization Management Committee.
  • Participate and/or Co-Chair in other committees as directed by CMO including Medical Advisory, Credentialing, Quality, Pharmacy and Therapeutics, Community Advisory, and Provider Advisory committees.

POSITION QUALIFICATIONS

  • Represent Gold Coast Health Plan to the community and collaborate with partner organizations.
  • Collaborate in strategic planning and execution of GCHP and DHCS strategic initiatives as directed by CMO.
  • Must be able to travel outside the office and/or attend meetings during and after hours; maintain professional growth and development through seminars, workshops, in-service meetings, current literature, and professional affiliations to keep abreast of latest trends in field of experience.

Competency Statement(s):

  • Department Management – Able to manage all employees of the department and responsible for the performance management and hiring of employees within that department.
  • Accountability – Ability to accept responsibility and account for their actions.
  • Accuracy – Ability to perform work accurately and thoroughly.
  • Communication, Oral – Ability to communicate effectively with others using the spoken word.
  • Communication, Written – Ability to communicate in writing clearly and concisely.
  • Ethical – Ability to demonstrate conduct conforming to a set of values and accepted standards.
  • Leadership – Ability to influence others to perform their jobs effectively and to be responsible for making decisions.
  • Organized – Possessing the trait of being organized or following a systematic method of performing a task.
  • Relationship Building – Ability to effectively build relationships with customers and co-workers.
  • Management Skills – Ability to organize and direct oneself and effectively supervise others.
  • Decision Making – Ability to make critical decisions while following company procedures.

SKILLS & ABILITIES

Education:

  • Doctorate required, field of study: Primary Care Specialty (Internal Medicine, Pediatrics, Family Practice).
  • MD/DO degree from an accredited college or university, preferably in a primary care specialty. Board certified in specialty: required.

Experience:

  • 5+ years of experience in clinical/medical practice.
  • 3+ years of experience in managed care plan is required.
  • Experience administering medical programs is required. Knowledge of Quality Improvement, Care Management and Utilization Management resources management procedures.
  • Experience with, and acceptance of, managed health care delivery systems and philosophy.
  • Knowledge of Medicaid is required; California Medi-Cal programs strongly preferred.
  • Experience integrating clinical and financial data for improved management of clinical programs.
  • Familiarity with the Ventura County Medical Community preferred.

Certifications & Licenses:

  • Current, valid, unrestricted California medical license or ability to obtain a CA medical license prior to date of appointment.
  • Current Board Certification (primary care preferred).
  • Possession of, or ability to obtain, a valid appropriate California driver’s license.
  • Maintain a satisfactory driving record.

Computer Skills:

  • Advanced computer skills included in MS Office products.

Other Requirements:

  • Principles relating to administration, organization, planning, and management of key business issues in the health care industry.
  • Knowledge of Medicaid and other related business and policies governing managed care issues; health care economics, personnel administration, federal, state and local laws, marketing, financial and cost analysis, trends in the health care industry, and primary health care administrative theory and practice.
  • Principles and practices of contract administration and evaluation.
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