Cencal Health
Job DetailsJob LocationMain Office - Santa Barbara, CAPosition TypeFull TimeSalary Range$281107.00 - $449771.00 Salary/yearJob CategoryHealth ServicesDescriptionCentral Coast Salary Range-$281,107 - $449,771Candidates for this position must reside on the Central Coast (Ventura, Santa Barbara, San Luis Obispo, Monterey and Santa Cruz Counties) or be willing to relocate to the area upon hire. As a community-facing role, a local presence is essential to effectively engage with and serve our community. Please note that relocation assistance may be available.Job SummaryReporting to the Chief Medical Officer, or his/her designee, 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. This position will work a hybrid or remote schedule depending on business needs.Duties and ResponsibilitiesProvides 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 supervise other Health Services staff in the future.May participate in committee assignments such as Credentialing, Peer Review, Pharmacy & Therapeutics, and/or Quality Improvement as well as JOC (Joint Operating committee) meetings.Other duties as assigned, such as on-call duties related to post -stabilization care services.May participate in special projects such as those related to NCQA certification and implementation of the Medicare D-SNP line of business.QualificationsKnowledge / Skills / AbilitiesIn-depth knowledge of the principles and practices of managed care related to utilization management and case management and discharge planning.In-depth knowledge of the healthcare, economic or other issues affecting Medi-Cal and/or Medicare populations, providers and the underserved in Santa Barbara and San Luis Obispo Counties and surrounding areas.Basic knowledge of managed healthcare as applied to government sponsored programs including Medicaid.Strong knowledge of and ability to identify, implement, monitor and analyze relevant metrics models, and implement effective interventions based on results.In-depth knowledge of standard contract components and contract language specific to healthcare.In-depth knowledge of audit, control and monitoring processes, and the ability to effectively implement and maintain them.Understanding of population health concepts and social determinants of health.Very strong facilitation, problem solving and conflict resolution skills.Ability to create, execute and monitor relevant strategic and business plans.Strong collaboration skills with demonstrated ability to create and foster a collaborative, team based, work environment, maintain effective, high performance teams, and organize people and resources to solve problems and identify business opportunities.Very strong interpersonal skills, with the ability to establish and maintain effective working relationships with individuals at all levels inside and outside of CenCal. Effective building teams and consensus.Very strong oral and written communication skills, with the ability to communicate professionally, effectively and persuasively to diverse individuals and groups inside and outside of CenCal.Strong presentation skills, including the ability to tailor presentations to a specific audience, and address and interact with large groups.Demonstrated ability to articulate and embrace organizational values, integrate into management practices, and foster their manifestation among staff.Strong customer service skills.Strong project management skills.Intermediate skills in Word and Excel.Ability to supervise staff, and ensure that direct reports supervise staff, in a manner that maximizes employee performance and business results.Ability to speak and be understood in English.Ability to handle confidential information with appropriate discretion.Education and ExperienceMD/DO degree from an accredited medical school.Satisfactory completion of an American Council of Graduate Medical Education or American Osteopathic Association accredited residency program.At least three - five (3-5) years clinical experience in the practice of medicine.3-5 years of experience doing Medi-Cal and Medicare Utilization Management/Case Management for a health plan, IPA, or other similar medical Management entity is preferred.Unrestricted license to practice medicine in the State of California, issued by the State Board of Medical Examiners, which meets the Health Plan's credentialing and re-credentialing requirements.Board Certification required.Valid California driver license with a clean driving record and reliable transportation or, the ability to obtain transportation on demand in the counties served by CenCal if prohibited from getting a driver license due to a medically documented disability.