Senior Medical Director

The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California and future increases will be based on the pay band for the city and state you reside in.

Work Culture:

GCHP strives to create an inclusive, highly collaborative work culture where our people are empowered to grow and thrive.  This philosophy enables us to create the health plan of the future and do our best work – Together.

GCHP promotes a flexible work environment. Employees may work from a home location or in the GCHP office for all or part of their regular workweek (see disclaimer).

GCHP’s focuses on 5 Core Values in the workplace:

•    Integrity

•    Accountability

•    Collaboration

•    Trust

•    Respect

Disclaimers:

• Flexible work schedule is based on job duties, department, organization, or business need.
• Gold Coast Health Plan will not sponsor applicants for work visas.

Position Summary

The Senior Medical Director (SMD) is a key leadership position within Gold Coast Health Plan’s Health Services Department. The SMD role will work in close coordination with the Chief Medical Officer (CMO), supporting key functions under the Office of the CMO, which includes Quality Improvement (QI), Clinical Quality Improvement, Pharmacy, Care Management Health Equity, and Utilization Management (UM) Departments. Role works to assist the CMO in the successful execution of planning and operational responsibilities. The SMD will provide direct guidance/consultation/training of Utilization Management, Care Management, Quality Improvement, Clinical Quality Improvement, and Pharmacy Departments while also assisting other GCHP Department with other critical functions as assigned by the CMO.  

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 Statements

Duties And Responsibilities

• Provides guidance, consultation, and training to Utilization Management Department staff in collaboration with the Health Services Executive Director
• Provides guidance, consultation, and training to Pharmacy Department staff in collaboration with the Director of Pharmacy.
• Provides direct support and guidance to Credentialing staff
• Provide direct support, guidance, and training to Grievance and Appeals staff in collaboration with Operations and/or the Grievance and Appeal RN Senior Manager
• Provides direct support and guidance to the RN Senior Manager of Clinical Quality who oversees the Potential Quality Incident (PQI) team, and the Facility Site Review team
• Provides clinical support, thought partnership to the CMO and direct reports for all areas of the Office of the CMO, including Health Services, Quality Improvement, Clinical Quality Improvement, Management, Health Equity, and Pharmacy departments
• Ensures and helps maintain Office of the CMO department compliance and maintenance of CMS, DHCS, DMHC, NCQA, and other regulatory and certification agency standards
• Attends or chairs, at the discretion of the CMO, committees such as Utilization Management, Credentialing, Medical Advisory, Quality Improvement and Pharmacy
• Supports development of Interdisciplinary Care Team (ICT) model and participates in ICT rounds
• Participates in health plan on-call physician rotation
• Assumes CMO responsibilities when CMO is unavailable due to scheduled vacation or unexpected absences
• Oversees and supports GCHP contracted medical review physicians, and GCHP medical directors
• Provides Office of the CMO department support and leadership

     o    Supports the Executive Director of Health Services

     o    Supervises and supports contracted GCHP medical review physicians

     o    Supports the development of UM department to meet DHCS and CMS requirements

     o    Ensures the evaluation and authorization of prior authorization requests within all mandated timeframes

     o    Ensures the appropriate selection and application of GCHP’s medical necessity criteria hierarchy in the rendering of RN and medical review physician, medical director determinations based on medical necessity

     o    Provides support for nurse reviewers and manages the medical review physician and medical director roles in the prior authorization and concurrent review process

     o    Reviews cases with concurrent review nurses

     o    Provides medical expertise for coordination with care management

     o    Monitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost-efficiency, and continuity of care

     o    Assists with retrospective claims reviews of claims and appeals. Reviews and resolves grievances related to medical quality of care

     o    Works collaboratively with Operations and the Grievance and Appeal RN Senior Manager to ensure compliance with GCHP policies/Procedures, and DHCS’ Member Grievance process regulatory requirements

     o    Ensures that clinical decision making is rendered by appropriately licensed medical personnel based on established medical necessity criteria and decisions are not influenced by fiscal or administrative management considerations

     o    Ensures that the medical care provided by the GCHP provider network meets established GCHP clinical guideline policy standards

     o    Ensures that medical protocols and rules of conduct for plan medical personnel are followed

     o    Collaborates with the CMO, and Office of the CMO Department Directors to develop and implement clinical policies/procedures

     o    Implements Quality Improvement activities

     o    Educates and interacts with network and group providers, their office/clinic managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management

     o    Works collaboratively with Provider and Network Operations (PNO) to support contract issues/negotiations with the GCHP provider network

     o    Supports the GCHP teams that identify and resolve Network provider UM/QI/Member Grievance/PQI/Credentialling issues

     o    Regularly reviews UM bed day data, Operations Claims data, and other clinical data reports, and recommends corrective actions/intervention with the CMO, Health Services Executive Director, UM Committee, and/or the GCHP Quality Improvement Health Equity Committee

     o    Interfaces collaboratively with other GCHP departments to coordinate operations and programs

     o    Provides clinical leadership and support to medical management system implementation and configuration

     o    Represent GCHP CMO and GCHP in regulatory, professional and community activities to provide GCHP input and become knowledgeable regarding regulatory, professional and community standards

•    Provides clinical leadership in Pharmacy Department 

     o    Support and work collaboratively with the Pharmacy Director and the pharmacy department team

     o    Works with the Pharmacy Director to develop new or refine pharmacy department programs

     o    Provides clinical expertise to pharmacy department team members

     o    Ensures the evaluation and authorization of pharmacy requests within all mandated timeframes

     o    Provides support and clinical expertise for pharmacy department programs and initiatives related to CMS, DHCS, DMHC, NCQA, and other regulatory and certification agencies

Knowledge, Skills, and Abilities

• Knowledge of NCQA, HEDIS, MCAS, DHCS/MediCal program requirements and regulations, CMS regulations, Medicare and Pharmacy benefit management, Group/IPA practice models, capitation models, value based reimbursement models, CA HMO regulations, managed healthcare systems, quality improvement programs, medical utilization management programs, risk management, Medicare risk adjustment, disease management programs, evidence-based medical necessity guidelines, and current clinical knowledge
• Knowledge of management practices, human relations, consensus building and finance
• Excellent interpersonal communication skills, demonstrated ability positively influence physicians, motivate teams
• Demonstrated Executive Presence
• Professionally respected by peers
• Physical capacity and personal transportation availability to commute to and from corporate offices, Staff Model Offices and provider offices and facilities as necessary
• Ability to abide by Gold Coast Health Plan’s policies
• Ability to maintain attendance to support required quality and quantity of work
• Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA)
• Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers

Non-Essential Functions

•    Other duties as assigned by the GCHP CMO. 

Position Qualifications

Competency Statements

• Management Skills - Ability to organize and direct oneself and effectively supervise others.
• Business Acumen - Ability to grasp and understand business concepts and issues.
• Decision Making - Ability to make critical decisions while following company procedures.
• Goal Oriented - Ability to focus on a goal and obtain a pre-determined result.
• Interpersonal - Ability to get along well with a variety of personalities and individuals.
• Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.
• Time Management - Ability to utilize the available time to organize and complete work within given deadlines.
• Consensus Building - Ability to bring about group solidarity to achieve a goal.
• Relationship Building - Ability to effectively build relationships with customers and co-workers.
• Presentation Skills - Ability to effectively present information publicly.
• Delegating Responsibility - Ability to allocate authority and/or task responsibility to appropriate people.
• Leadership - Ability to influence others to perform their jobs effectively and to be responsible for making decisions.
• Strategic Planning - Ability to develop a vision for the future and create a culture in which the long-range goals can be achieved.
• Ethical - Ability to demonstrate conduct conforming to a set of values and accepted standards.
• Judgment - The ability to formulate a sound decision using the available information.
• Communication, Oral - Ability to communicate effectively with others using the spoken word.
• Communication, Written - Ability to communicate in writing clearly and concisely.
• Problem Solving - Ability to find a solution for or to deal proactively with work-related problems.

Skills & Abilities

Required Education:

• Doctorate Degree in Medicine.
• Board Certification in a medical specialty.

Preferred Education: Board Certified in primary care preferred

Required Experience:

• At least 5 years of Medical Director or equivalent medical leadership role
• At least 5 years of Utilization/Quality Program Management experience
• At least 5 years of clinical practice
• At least 5 years of HMO/Managed Care experience

Preferred Experience:

•    Peer Review, credentialing, quality improvement, medical policy/procedure development, provider contracting experience.

Computer Skills: Proficient computer skills included in the MS Office products. 

Certifications & Licenses: Current California Medical license without restrictions to practice and free of sanctions from Medicaid or Medicare.