Medical Director - Peds

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 Summary Under the direction of the Chief Medical Officer (or their designee), the Medical Director is responsible for the following:Oversee Clinical Aspects of Key Functions:The Medical Director is responsible for overseeing clinical aspects of utilization management, quality improvement, care management, and credentialing.Ensure High-Quality, Cost-Effective Healthcare Delivery:Ensure that healthcare services are delivered in a way that meets high-quality standards, is cost-effective, aligns with organizational goals, and complies with contractual and regulatory requirements.Exercise Discretion and Independent Clinical Judgment:Make complex decisions that require a high level of discretion and independent judgment within the scope of clinical operations and leadership.Support Member and Provider Needs:Maintain a strong focus on the needs of CenCal Health's members and providers, ensuring that clinical programs and initiatives serve their best interests.Duties and ResponsibilitiesOversee Clinical Aspects of Key Functions(Utilization Management, Quality Improvement, Care Management, and Credentialing):Provides clinical leadership for medical management functions and supports subordinate managers in addressing medical claims reviews, grievances, appeals, and other related medical management issues.Conducts clinical reviews and makes utilization management (UM) decisions for prior, concurrent (hospital/skilled nursing facility), retroactive authorizations, and appeals; approves/denies requests or offers medical alternatives in line with CenCal Health's medical review criteria; engages with providers by phone or in person as needed; develops UM policies and procedures in coordination with Health Services staff.Provides clinical oversight and develops care management strategies and opportunities.May participate in committee assignments such as Credentialing, Peer Review, Pharmacy & Therapeutics, Quality Improvement, and/or Joint Operating Committee (JOC) meetings.May support population health initiatives.Currently has no direct reports but may supervise other Health Services staff in the future.Ensure High-Quality, Cost-Effective Healthcare Delivery:Identifies, analyzes, and assists in addressing quality issues and trends, offering recommendations based on findings and driving the implementation of agreed-upon improvements.Works collaboratively with the Pharmacy team to ensure the clinical appropriateness of medication utilization.Committed to continuous process improvement and organizational efficiency.Collaborates with the CMO and other medical directors to identify medical service issues affecting plan benefits and their administration, develops action plans, and monitors outcomes.Exercise Discretion and Independent Clinical Judgment:Provides clinical expertise to effectively resolve complex, controversial, or unique administrative situations, collaborating with internal and external teams as needed.May be involved in special projects as assigned by the Chief Medical Officer, and in line with the Medical Director's prior experience, expertise, and areas of interest.Other duties assigned include on-call responsibilities related to post-stabilization care services.Support Member and Provider Needs:Build and maintain relationships with providers, provider organizations, and other stakeholders to support contracting, provider relations, marketing, and other organizational objectives.QualificationsKnowledge / Skills / AbilitiesExtensive expertise in managed care principles and practices, with a strong focus on utilization management, case management, and discharge planning.Deep understanding of healthcare, economic, and policy-related issues affecting Medi-Cal and/or Medicare populations, providers, and underserved communities, particularly in Santa Barbara, San Luis Obispo Counties, and surrounding regions.Foundational knowledge of government-sponsored managed healthcare programs, including Medicaid.Skilled in identifying, implementing, monitoring, and analyzing key metrics and models to design and execute effective, data-driven interventions.Thorough understanding of healthcare contract structures, language, and key components.Strong knowledge of audit, control, and monitoring methodologies, with the ability to implement and sustain effective compliance processes.Familiarity with population health strategies and the social determinants of health impacting access and outcomes.Exceptional skills in facilitation, conflict resolution, and problem-solving.Demonstrated success in developing, executing, and tracking strategic and operational business plans.Highly collaborative, with a proven ability to foster team-oriented environments, build and lead high-performing teams, and strategically align resources to overcome challenges and pursue business opportunities.Excellent interpersonal abilities, capable of building and maintaining strong relationships across all organizational levels and with external stakeholders; skilled in promoting teamwork and building consensus.Outstanding verbal and written communication skills, with the ability to deliver messages clearly, persuasively, and professionally to diverse audiences, both internally and externally.Strong public speaking and presentation skills, with the ability to tailor content effectively to varied audiences and engage large groups confidently.Committed to upholding and modeling organizational values in leadership practices and fostering their integration throughout the team.Proven track record of delivering exceptional customer service.Strong project management skills, with the ability to plan, execute, and manage initiatives to successful outcomes.Proficient in Microsoft Word and Excel.Effective leadership skills, with the ability to supervise staff, support team development, and drive employee performance to meet business goals.Fluent in spoken English, with clear and effective verbal communication.Trusted to handle sensitive and confidential information with the highest level of discretion and integrity.Education and ExperienceRequired:Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree from an accredited medical school.Successful completion of a residency program accredited by the Accreditation Council for Graduate Medical Education (ACGME) or the American Osteopathic Association (AOA).Minimum of three to five (3-5) years of direct clinical practice experience.Current and valid license to practice medicine issued by the CA Board of Medical Examiners or the CA Board of Osteopathic Medicine, and meeting CenCal Health's credentialing and re-credentialing requirements.Board Certification in a clinical specialty as approved by the American Board of Medical Specialties (ABMS).Possession of a valid California driver's license with a clean driving record and access to reliable transportation; alternatively, individuals with a medically documented disability who are unable to obtain a driver's license must have the ability to secure appropriate transportation within CenCal Health's service areas.Preferred:Three to five (3-5) years of experience in Medi-Cal and Medicare Utilization Management and/or Case Management within a health plan, Independent Practice Association (IPA), or similar medical management organization.