job

Under the direction of the Chief Medical Officer, the Vice President, Health Services:

• Provides executive medical leadership across the Health Services Departments. This includes direct oversight and management of the Utilization Management medical directors as well as provision of clinical leadership and strategic direction across Health Services in partnership with the Vice President, Health Services Clinical Integration and Operations and Senior Director of Medical Management.
• Works closely with the Health Services leadership team on Utilization Management activities and complex clinical cases.
• Has a lead role in regulatory audits (DHCS, DMHC, CMS, NCQA).
• Participates in the development of potential new business lines, rising risk and high-risk member programs, integrated care models, population health strategies including involvement in assigned state initiatives (CalAIM), hospital relations, oversight of provider and IPA utilization and performance, strategic plan implementation, and coordination with the Quality and Grievance & Appeals Departments.
• Serves as a mentor to medical directors and clinical staff to foster professional growth and development.
• Represents the CMO internally and externally and serves as a spokesperson on medical issues in the absence of the CMO.

• Lead and support direct reports that includes Senior UM Medical Director and Special Programs Manager. Potential for other direct reports based on organization chart restructuring.
• Provide clinical and strategic direction to the Utilization Management Department. Partner with Senior Director of Medical Management and other key leaders in the development of UM polices/procedures and design and implementation of clinical and non-clinical programs and interventions across the spectrum of healthy, rising risk, and high-risk members as well as transitions of care.
• Has lead role in ensuring compliance with regulatory requirements, audit response, and assuring audit readiness (DHCS, DMHC, CMS, NCQA) related to medical management and quality oversight.
• Serve as a point of contact for clinical, quality, and performance issues in the IEHP network and establish ongoing relationships with network physicians, medical groups, hospitals, and County Health Systems.
• Serve as coach and mentor to support the professional growth of medical directors and associate medical directors.
• Partner with the Chief Quality Officer, Chief Financial Officer, and Chief Operating Officer on network strategy, network performance improvement, quality improvement, and value-based care contracts.
• Provide oversight of the clinical components of delegation oversight and partner with the Senior Director within Health Services to provide effective oversight and performance monitoring of IEHP delegate entities.
• Interface with and participate in public committees, leaders of regulatory agencies, State workgroups, network partners, and the medical community.
• Partner with the CMO and Vice President of Health Services Clinical Integration to provide clinical direction of Health Services that aligns with IEHP’s strategic plan and goals. May lead specific Strategic Plan Enterprise Goal and/or Strategy elements.
• Partner with the CMO and Vice President of Health Services Clinical Integration in the development and implementation of future new managed care lines of business.
• Lead and support key functions in the development and implementation of statewide initiatives such as CalAIM.
• Lead on development and implementation of Covered California UM policies.
• Key role in IEHP internal committees such as Credentialing, Peer Review, UM, and Quality.
• Provide clinical support on complex clinical cases, including outreach to providers, hospitals, and Members to resolve issues.
• Other activities and projects as assigned by the CMO.

Experience:

• Eight (8) years of post-residency clinical experience in a recognized medical specialty. Proven leadership experience, mentoring, and developing a team at a leadership level. Of the eight (8) years of experience required:
  • At least three (3) years of medical management experience in a lead role.
• Experience with regulatory agencies.
• Experience working in a medical group, IPA, Plan, or hospital setting in a leadership role preferred.

Education:

• Doctorate of Medicine or Doctorate of Osteopathic Medicine from an accredited institution required.

Professional Certification:

• Certification by one (1) of the American Specialty Boards.

Professional Licenses:

• Possession of an active, unrestricted, and unencumbered Physician’s and Surgeon’s Certificate issued by the State of California Medical Board required. (A physician certified in a state other than California may be employed prior to receipt of California certification provided that an application for a California physician and surgeon’s certificate is filed in the state of California prior to date of appointment at IEHP.)

• Utilization management, evidence-based care models, population health, clinical quality, and Managed Care principles.
• CMS and Medi-Cal program.
• Administrative practices and procedures (including but not limited to utilization review, peer review, credentialing, and risk management); rules regulations, policies, and standards related to managed care.
• Principles of effective supervision and organization; methods, techniques, practices, and literature in the broad field of medical sciences; and overview of the highly specialized techniques, procedures, and equipment used in the medical or surgical specialties.

Skills:

• Excellent oral and communication skills, including active listening.
• Excellent collaboration skills for work with network providers and internal employees.
• Proficient in Microsoft Office Suite, including Microcomputer applications such as Microsoft Word, Excel, and Access helpful.

Abilities:

• Highly effective and active communicator who works well with people at all levels.
• High-energy, persistent, assertive, data driven, accountable, and focused.
• Demonstrated ability to:
  • Implement and lead new and improved clinical approaches to improvement of care and service quality.
  • Design, lead, and implement overall regional population health and integration strategies.
  • Lead multidisciplinary teams, even when Team Members are not in direct line of authority.
  • Engage and develop relationships with network providers, with a high degree of patience.
  • Be highly collaborative, cross-functional, and systematic.
  • Work with high degree of diplomacy, credibility, and persuasiveness to consistently cultivate effective working relationships.
  • Effectively express ideas and gain their acceptance.
  • Be proactive and action oriented.
  • Drive performance and be persistent in accomplishing difficult tasks.
  • Actively seek out and support collaborative thinking and problem solving with others in the organization.
  • Operate with an open leadership style.

Commitment to Team Culture:
The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members, and associates outside of our organization.

Working Conditions:
While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools, or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch, or crawl; talk or hear; and taste or smell. The employee must occasionally lift or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.

Position is eligible for Hybrid work location upon completing the necessary steps and receiving HR approval. All IEHP positions approved for telecommute or hybrid work locations may periodically be required to report to IEHP’s main campus for mandatory in-person meetings or for other business needs as determined by IEHP leadership.

IEHP Team Members are expected to ensure the privacy and security of PHI (Protected Health Information) as outlined in IEHP’s policies and procedures related to HIPAA compliance.

The position purpose, principal accountabilities, essential functions, minimum qualifications, and the requirements listed in this position description are representative only and are not exhaustive of the tasks that a Team Member may be required to perform. IEHP reserves the right to revise this job description at any time and to require Team Members to perform other tasks as circumstances or conditions of its business considerations or work environment change.