Facility: Health PlanCity San DiegoDepartmentJob StatusRegularShiftDayFTE1Shift Start TimeShift End TimeDoctor of Osteopathic Medicine (DO); California Physicians and Surgeons License - Medical Board of CA; Doctor of Medicine (MD)Hours :Shift Start Time:8 AMShift End Time:5 PMAWS Hours Requirement:8/40 - 8 Hour ShiftAdditional Shift Information:Weekend Requirements:No WeekendsOn-Call Required:NoHourly Pay Range (Minimum - Midpoint - Maximum):$130.140 - $167.923 - $205.705The stated pay scale reflects the range that Sharp reasonably expects to pay for this position. The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant’s years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.What You Will DoThis Senior Medical Director position provides critical management and oversight for Sharp Health Plan's (SHP) physicians (Medical Directors (both medical and behavioral health) and the Physician Reviewers) to coordinate the necessary co-management of our members related to their medical, behavioral health and pharmacy needs.This position also provides the physician cohesive collaboration necessary for the continuum of care foundation for our NCQA required population health management program.Additionally, this position provides the representation of physician's insight, perspective and leadership on the Health Services Management team and the other strategic and operational leadership, projects and meetings throughout the SHP.This position oversees all physician management and medical care and for all of Sharp Health Plan products, (Commercial, Exchange, Medicare, POS/PPO) services, and oversees the health care needs of the membership. Serves as a lead medical manager and policy advisor to SHP clinical and its' Chief Medical Officer.Required Qualifications
Doctor of Medicine (MD) - Internal Medicine or Family Practice
OR Doctor of Osteopathic Medicine (DO) - Internal Medicine or Family Practice.
15 or more years of clinical practice of medicine.
5 years' experience as an HMO Health Plan Medical Director.
California Physicians and Surgeons License - Medical Board of CA -REQUIRED
Other Qualification Requirements
Unrestricted license CA MD/DO license required.
Essential Functions
Provides critical management and oversight for the Plan's physicians (Medical Directors (both medical and behavioral health) and the Physician Reviewers) to coordinate the necessary co-management of our members related to their medical, behavioral health and pharmacy needs.
Responsible and accountable to the Chief Medical Officer for helping to manage health plan medical costs and assuring appropriate health care delivery for SHP's products and services. Reports organizationally to the Chief Medical Officer.
Provides the representation of physician’s insight, perspective and leadership on the Health Services Management team and the other strategic and operational leadership, Projects and meetings throughout the Plan.
Works collaboratively with other plan functions that interface with medical management such as provider relations, member services, benefits and claims management, IT management, etc.
Plans, organizes, and directs the professional medical services program, consisting of all primary and specialty services for in-patient, out-patient, preventive and wellness programs.
Develops and Implements health plan clinical policies, goals and objectives.
Provides professional leadership and direction to the functions within the Medical Management Department (Utilization/Cost Management and Quality Management)
Develops and updates Physician management department work plan.
Responsible for and assists with the development of staffing plans and assuring the adequate allocation of resources to the medical management functions.
Responsible and accountable for implementing the Utilization/Cost Management Program and Quality Improvement Program, in conjunction with the Director of PHM/ Medical Management and Quality Improvement Director.
Oversees and mentors Medical Directors and Physician Reviewers.
Actively engages with SHC leaders in Physician Experience Council, Physician Leadership Academy and other key physician leaders to promote quality of care in a timely, efficient, effective and equitable manner.
Assists the Chief Medical Officer with activities to promote positive community relations.
Assures plan conformance with legal and regulatory requirements.
Assists CMO in continued builds strong partnerships with Medical Director PMGs and their clinical teams.
Assists CMO in the implementation of NCQA top decile improvement programs and work plans.
Assists the Chief Medical Officer and the Quality Improvement Director in creating and maintaining a system that gives feedback to providers individually and collectively regarding managed care effectiveness of individual providers and networks.
Assists the Chief Medical Officer in designing and implementing corrective action plans to address issues and improve plan and network managed care performance.
Collaborates with Chief Medical Officer in creating and maintaining programs that incentivize providers to achieve selected utilization/cost and quality outcomes.
Participates in policy review, performs analysis and makes recommendations for updating current polices to meet accreditation and regulatory requirements
Ensures newly updated EHB’s are updated and implemented into policies.
Participates in the retrospective review and analysis of Plan performance from summary data of paid claims, encounters, authorization logs, complaint and grievance logs and other sources.
Achieves and maintains benchmarked utilization and cost management (UM) goals and clinical quality improvement (QI) objectives, in conjunction with the Director of Medical Management/PHM and Quality Improvement Director.
Provides periodic written and verbal reports and updates as required in program descriptions, Annual Work Plans and policy and procedures to various plan committees, and the SHP Chief Medical Officer.
Supports NCQA survey activities. Prepares for site visits and responds to accrediting and regulatory agency feedback.
Supports pre-admission review, utilization management, and concurrent and retrospective review Process. Performs and mentor's physician training of A&G and UM platforms.
Oversees A/G and UM reviews of all clinical reviewers.
Participates in risk management reviews.
Assists in pharmacy utilization management, catastrophic case review, outreach programs, HEDIS reporting, site visit review coordination, triage, provider orientation, credentialing, profiling, etc.
Conducts quality improvement and outcomes studies as directed by the Quality Management
Committee, Peer Review Committee and Chief Medical Officer and reports findings in conjunction with the Quality Improvement Director.
Assists in POS/PPO Case Management and high-cost review with CMO and Claims management teams.
Co-Chairs with the CMO CPTAC and Peer Review Committees.
Partners with Senior Management including CMO and COO to prepare ongoing requests for statements and reviews for DMHC.
Participates in the grievance process with the Chief Medical Officer, insuring a fair outcome for all members.
Monitors member and provider satisfaction survey results and implements changes as needed to increase satisfaction and assure that satisfactory relationships are maintained between network and plan participants.
Participates in SHP Advisory Committees which include (but are not limited to) the Quality Management Committee, P and T and Joint Operations Committees with the PMGs.
Participates in key marketing activities and presentations, as requested.
Promotes wellness and ensures programs of prevention, education and outreach to members and providers are consistent with SHP's mission, vision and values.
Maintains up-to-date knowledge of new information and technologies m medicine and their application to SHP.
Performs and oversees in-service staff training and education of professional staff.Represents SHP at medical group meetings, conferences, etc.
Participates in the development of strategic planning for existing and expanding business.Recommends changes in program content in concurrence with changing markets and technologies.
Participates in key marketing activities and presentations, as necessary, to assist the marketing effort, as requested.Ensures that the Utilization Management staff is available on a 24-hour basis to respond to authorization requests for emergency and urgent services and is available, at a minimum, during normal working hours for inquiries and authorization requests for non-urgent health care services.
Performs other duties as requested or assigned.Collaborates with the Director of PHM/ Medical Management to guide and direct staff in relation to medical issues and departmental responsibilities. Assists in monitoring, reviewing, and evaluating the quality of health care services provided and the appropriateness of health care resources utilized, and communicates with PMGs and Plan providers as needed. Addresses physicians' issues and educates providers with regard to Plan policy as needed.Completes and/or supervises the completion of all clinical appeals and grievances. Collaborates with Customer Care Manager to identify trends in grievances. Supervises the process for identifying Potential Quality Issues.
Supervises Physician Reviewer(s) and Medical Directors including Behavioral Health Medical Directors.Shares after-hours coverage responsibilities with other Plan physiciansAssists the CMO, as needed, to oversee the credentialing process.
Assists in the development and interpretation of the covered benefit provisions of member materials and Plan contracts. Assists in the development and implementation of new benefits packages.Maintains appropriate contacts with membership in community and professional organizations.Serves on the SHP Benefit Council to support the requirements of Health Services.
Knowledge, Skills, and Abilities
Strong clinical ackground and skills.
Solid understanding of utilization management and quality assurance activities.
Excellent communication skills, both verbal and written.
Strong interpersonal skills, including the ability to interface effectively with employees, members, physicians, senior management, and the public at large.
Management skills to meet the organizational goals.
Knowledge of regulatory and accreditation agencies and requirements.
Able to manage multiple priorities and deadlines in an expedient and decisive manner.
Able to manage difficult peer situations arising from medical care review.
Appreciation of cultural diversity and sensitivity towards target population.
Demonstrates commitment to the organization, co-workers and subordinates.
Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class.#LI-CC1#relo#signon