Medical Director, Risk Adjustment

Medical Director, Risk Adjustment #UHM-2950

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Area of Interest

Utilization/Quality Management

Position Type

Full-time

Job Description

The Medical Director of Risk Adjustment is responsible and accountable for the performance of a specific region in terms of RAF score for all product lines that risk adjust and quality scores for all product lines. The Medical Director will be working with internal staff, larger and exclusive PCPs, and CFO to ensure performance of the assigned region.

The Medical Director must have outstanding personal skills and communication skills given the amount of time they will be interacting with physicians, internal staff and office staff. They must have excellent clinical skills in order to analyze medical information, consider differential diagnoses and suggest diagnoses that are applicable to patients. The Director must be detailed-oriented and result-driven. The Medical Director should behave in a professional manner when interfacing with Medical Directors, physicians, office staff and other internal and external customers.

Essential Duties and Responsibilities include the following:

• Understand finances of the program and become an expert in HCC and the company’s programs.
• Build relationships with all of the exclusive PCPs and high volume PCPs within the assigned region. As part of the relationship building, they should meet with these providers on a monthly basis. The Medical Director must also ensure these providers are in compliant with company’s needs.
• Achieve access to exclusive PCP’s EMR to facilitate information retrieval and chart reviews.
• Ensure all assigned providers attend annual training seminars.
• Grant access to qHMO for PCPs and train them on qHMO and ensure they are utilizing the system and information.
• Attend town halls in assigned region and cultivate message that is consistent with company’s goals and priorities.
• Be instructor at all of the annual seminars scheduled in assigned region.
• Manage and provide direction to designated internal staff. This responsibility includes on-going training, provide direction, and monitor their productivity and their performance. In addition, the Director will be responsible for designated employees HR items such as ADP, performance reviews, PTO requests, compliance trainings, and other HR requirements, as needed.
• Understand vendors that are being utilized in their regions as to support the initiatives without duplicating resources.
• Perform chart reviews and collect records from providers, as needed. When performing chart reviews, must input findings into qHMO.
• In order to ensure successful performance, the Medical Director must utilize member level data that is available to target patients to be seen.
• Director may need to do functions of HCC Physician Trainers such as meeting with PCPs and their staff to educate them on HCC and quality metrics. This includes providing information on HCC and quality, explaining our systems available to support the provider, processes recommended for the provider to incorporate and ensuring they achieve corporate goals related to risk adjustment and quality.
• Provide information in larger meetings of providers and internal staff to highlight program overviews and discuss updates, as needed.
• Work closely with CFO to ensure always updated on progress, issues and initiatives. Must work with supervisors to ensure company’s priorities and messages are being communicated as needed to other employees and providers timely and accurately.
• Work with STAR/P4P/HEDIS team to ensure providers are compliant with needed quality measures and to outreach to providers and retrieve information as directed by Medical Director.
• Manage the performance of HCC Physician Trainers .
• Work with coding team to relay information to providers to ensure compliance with coding rules and guidelines and improve provider’s documentation as advised by Senior Director.
• Remain updated on CMS’ HCC program, medical knowledge and NCQA HEDIS Technical Specifications as it applies to the HCC, STAR and ACO programs.
• Filing, faxing, copying and scanning of files, as needed.
• Strive to meet personal, departmental and organizational goals and targets.
• Must have ability to manage a heavy workload with frequent interruptions and changing priorities in a fast paced environment.
• Completes assignments within specified time lines.
• Able to work well in a team environment on special projects.
• Skill in working independently, but with supervision.
• Prepares and maintains records and files that are organized, thorough and readily accessible.
• Attend regular team meetings and report findings of data collection and projects.
• When identifies a problem, informs supervisor in a timely manner so the problem can be corrected.
• Transmits ideas and information in a clear and concise manner.
• Assist supervisor with special duties/projects.
• All other duties as directed by management.

Education and / or Experience:

• Graduate from accredited medical school
• Board certified (current)/eligible in own specialty
• Active California medical license
• Minimum of one year experience in clinical setting as either Family Practice, Internal Medicine
• Minimum of two years’ experience in Risk Adjustment
• Familiarity with managed care, commercial and point of service medical care preferred.
• Computer literate with knowledge and experience with specific software such as Word, Excel, Access.

The pay range for this position at commencement of employment is expected to be between $215,000 annually to $230,000 annually ;however, base pay offered may vary depending on multiple individualized factors, including markelocation, job-related knowledge, licensure, skills, and experience.

The total compensation package for this position may also include other elements, including a sign-on bonus and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offered.

Details of participation in these benefit plans will be provided if an employee receives an offer of employment.

If hired, employee will be in an “at-will position” and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.

As one of the fastest growing Independent Physician Associations in Southern California, Regal Medical Group, Lakeside Community Healthcare & Affiliated Doctors of Orange County, offers a fast-paced, exciting, welcoming and supportive work environment. Opportunities abound, and enterprising, capable, focused people prosper with us. We promote teamwork, nurture learning, and encourage advancement for all of our employees. We want to see you excel, because we believe that your success is our success.

Full Time Position Benefits:

The success of any company depends on its employees. For us, employee satisfaction is crucial not only to the well-being of our organization, but also to the health and wellness of our members. As such, we are firmly dedicated to providing our employees the options and resources necessary for building security and maintaining a healthy balance between work and life.

Our dedication to our staff is evident in our comprehensive benefits package. We offer a very generous mixture of benefits, including many employer-paid options.

Health and Wellness:

• Employer-paid comprehensive medical, pharmacy, and dental for employees
• Vision insurance
• Zero co-payments for employed physician office visits
• Flexible Spending Account (FSA)
• Employer-Paid Life Insurance
• Employee Assistance Program (EAP)
• Behavioral Health Services

Savings and Retirement:

• 401k Retirement Savings Plan
• Income Protection Insurance

Other Benefits:

• Vacation Time
• Company celebrations
• Employee Assistance Program
• Employee Referral Bonus
• Tuition Reimbursement
• License Renewal CEU Cost Reimbursement Program
• Business-casual working environment
• Sick days
• Paid holidays
• Mileage

Employer will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of the LA City Fair Chance Initiative for Hiring Ordinance.

Requirements

Education and / or Experience:

• Graduate from accredited medical school
• Board certified (current)/eligible in own specialty
• Active California medical license
• Minimum of one year experience in clinical setting as either Family Practice, Internal Medicine
• Minimum of two years’ experience in Risk Adjustment
• Familiarity with managed care, commercial and point of service medical care preferred.
• Computer literate with knowledge and experience with specific software such as Word, Excel, Access.