Regional Director of Clinical Operations for CommuniCare Health Services overseeing clinical policy compliance and managing nursing teams. Requires extensive experience in Long Term Care and Nursing Consulting.
About the role
- Senior Medical Director overseeing medical policies and health outcomes at IEHP, focusing on quality management and regulatory compliance. Role involves leadership and collaboration across departments in California.
Responsibilities
- Lead the development and execution of creating and/or updating medical policies and procedures to align with health plan regulatory requirements.
- Ensure guidelines and clinical pathways are updated with best practices, along with appropriate downstream connections to utilization management, population health, and other compliance and regulatory activities
- Lead, develop and implement clinical programs and medical policies to align with IEHP’s strategic priorities in order to improve member safety, quality of care and outcomes
- Lead clinically, through strong partnerships with other departments for activities related to member outcomes, quality improvement, grievance and appeals, and network corrective action plans.
- Develop and increase collaborative relationships with internal departments.
- Assure interdepartmental collaboration and communication with key business departments, including, but not limited to, compliance, member experience, provider relations, and claims.
- Serve as a liaison with providers, county public health partners and oversight agencies as assigned.
- Monitor network performance proactively to ensure adherence to policy standards.
- Develop and implement appropriate internal initiatives to address any issues impacting member outcomes
- Co-leadership with the Sr. Medical Director of Health Services to advance IEHP’s Mission, Vision and Values.
- Work in partnership with the Senior Medical Director focusing on UM to coordinate daily huddles, develop work schedules, adherence to department metrics and KPIs, and training of medical staff.
- Manage medical directors, as well physician reviewers, working in the domains of policy, outcomes, quality management and clinical guideline development.
- Provide clinical direction to the Health Service team and act as a resource to all IEHP departments responsible for providing or coordinating clinical services to IEHP members.
- Direct, implement, and/or enhance medical policy, internal policies, and job aids as it relates to member safety and quality management activities, clinical guideline development, delegation and oversight, credentialing, peer review, and compliance related activities.
- Ensure medical decisions are rendered by qualified medical personnel, unhindered by fiscal or administrative management, with timely and appropriate use of UM criteria and guidelines.
- Direct clinical and workflow training for medical directors and physician reviewers within their oversight.
- Ensure medical personnel of the Plan and its delegates follow IEHP policies, protocols and rules of conduct consistent with the values of IEHP.
- Identify gaps in policies or activities relating to member outcomes and implement strategic, effective solutions.
- Serve as a primary point of contact for clinical, quality and performance issues for medical directors at delegated IPAs, as well as for providers in the IEHP direct network.
- Support other departments as needed to ensure timely completion of member grievances and appeals as required for regulatory compliance.
- Provide clinical leadership, support and/or guidance including, but not limited to, the following areas: Pre-admission authorization, Prospective, concurrent and retrospective review, Inpatient case review, Inpatient claims reviews, Utilization review, Member case management, Provider incentive programs, Credentialing, Peer Review and Member Safety Subcommittees, Pharmacy and Therapeutics Subcommittee, NCQA Accreditation Reviews, State mandated benefits to ensure IEHP is in full compliance through its providers.
- Perform any other duties as required to ensure Health Plan operations and department business needs are successful.
Requirements
- Seven (7) years of post-residency experience in a recognized medical specialty or practice, which must have included at least three (3) years of medical administrative experience required
- Minimum of five (5) years of managed care or health plan leadership experience with proven track record of leading high performing physician teams
- Experience working with clinical practice guidelines and evidenced based criteria sets
- Has exposure to working with regulatory agencies
- Medical Director for an IPA, medical group, or CA HMO highly desirable
- Medical specialty/practice experience preferably in the state of California
- Doctorate of Medicine from an accredited institution required
- Certification by one (1) of the American Specialty Boards required
- Completion of an accredited residency program required.
- Possession of an active, unrestricted, and unencumbered Physician’s and Surgeon’s Certificate issued by the State of California 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.
Benefits
- Competitive salary
- Hybrid schedule
- State of the art fitness center on-site
- Medical Insurance with Dental and Vision
- Life, short-term, and long-term disability options
- Career advancement opportunities and professional development
- Wellness programs that promote a healthy work-life balance
- Flexible Spending Account – Health Care/Childcare
- CalPERS retirement 457(b) option with a contribution match
- Paid life insurance for employees
- Pet care insurance
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