Medical Director

OverviewHealth Services for Children with Special Needs, Inc (HSCSN) is a small Medicaid Managed Care Organization that administers the Child and Adolescent Supplemental Security Income Program (CASSIP) in the District of Columbia. HSCSN provides both physical health and behavioral health services. The Medical Director (for physical health) is a PRN physician leader in the Medical Affairs Department, reporting to the Chief Medical Officer. The Medical Director participates in Utilization Management and Care Management activities, uses evidence-based guidelines and clinical judgment, and collaborates with leadership to monitor, evaluate and improve the quality of health services delivered to HSCSN enrollees. The role leads cross-functional disease management programs related to physical health conditions (e.g., Asthma, Diabetes, Obesity) and serves as a clinical liaison with healthcare providers, community stakeholders, and government agencies. The Medical Director participates in organization-wide strategic, medical, quality, medical and business planning related to physical health. The position requires a physician licensed to practice in the District of Columbia with experience managing children with medical complexity and disabilities.ResponsibilitiesUtilization Management: completes second-level reviews of authorization decisions, participates in peer-to-peer discussions with relevant physicians, educates network providers, develops medical necessity criteria and medical policy for HSCSN, participates in rounds and discussions to assess enrollees, and evaluates utilization of services.Care Management: serves as a medical advisor to care management, helps lead disease management program development, design and implementation with cross-functional teams, and participates in staff education on HSCSN population topics.Quality Management: participates in provider and vendor oversight, investigates enrollee grievances as needed, and assists in developing quality and performance metrics with the CQO and Quality team.Coverage: available to perform duties during normal business hours, participates in on-call rotations as needed, and covers for the Chief Medical Officer during vacations or as needed.Organizational Accountabilities: demonstrates leadership excellence, collaboration, and leadership skills to improve quality of service and drive business results; fosters a safe environment for brainstorming and diverse, effective communication.QualificationsMinimum EducationMedical Doctor (M.D.) (Required)Minimum Work ExperienceAt least 5 years of clinical practice in a related specialty (Required); 2 years work experience with a managed care organization is preferred.Required Skills/KnowledgeFamiliarity with the Medicaid system; experience with the SSI eligible population; multidisciplinary team leadership.Required Licenses and CertificationsPhysician must be licensed to practice without restriction in the District of Columbia; board certification in Pediatrics, Internal Medicine or Family Medicine (Required).Job FunctionsUtilization Management: Completes second-level reviews of authorization decisions as assigned and within required timeframes.Utilization Management: Participates in peer-to-peer discussions with relevant physicians and educates network providers regarding options for care.Utilization Management: Assists in development of medical necessity criteria and other medical policy for HSCSN.Utilization Management: Participates in Home Care Rounds, Inpatient Rounds, and other internal team rounds to discuss HSCSN enrollees.Utilization Management: Assists with evaluation of utilization of services, including under and over-utilization.Care Management: Serves as a medical advisor to care management staff regarding diagnoses, services, and enrollee care plans.Care Management: Helps lead disease management program development, design, and implementation as part of a cross-functional team.Care Management: Participates in education of HSCSN Care Management and other staff regarding topics relevant to the HSCSN population.Quality Management: Participates in provider oversight, vendor oversight, and network adequacy activities.Quality Management: Participates in investigations of enrollee grievances as needed.Quality Management: Assists CQO and Quality team in developing quality and performance metrics.Coverage: Available to perform functions during normal business hours and participates in on-call rotations as needed; covers for the Chief Medical Officer during vacations and as needed.Organizational Accountabilities: Demonstrates leadership, collaboration, and accountability; fosters improvement in care and efficiency; aligns objectives to drive results.Job DetailsPrimary Location: District of Columbia-WashingtonWork Locations: HSCSN - Vermont Ave, 1101 Vermont Ave NW, Washington, DC 20005Job: Physicians / Physicians LeadershipOrganization: Strategic OperationsJob Posting: Aug 15, 2025, 5:00:15 PMDC Residents Encouraged to Apply. #J-18808-Ljbffr