Senior Medical Director

2 weeks ago

Renton, United States Cambia Health Solutions Full time

Senior Medical Director

Washington - includes in state and out of state travel

Single large employer focus

Primary Job Purpose

Senior Medical Director provides clinical leadership and support to clinical teams to ensure HCA members receive quality, cost effective care yielding optimal outcomes, supports HCAs Health Technology Assessment program, the Prescription Drug Program, the Bree Collaborative, HEDIS and CAHPs performance and quality program, and other the HCA-identified performance improvement efforts as they relate to the UMP Plans and the States health care purchasing system. This will include HCA customized medical policies and medical benefit design, WA state legislative mandates, clinical escalation support, participation in development of and organizational alignment to Bree Collaborative best practice recommendations, participation in development of care transformation strategic initiatives, and other requests from HCA.

General Functions and Outcomes

  • Provides clinical leadership for staff to ensure members receive safe, effective and cost efficient services.

  • Contributes to the development of various medical management strategies and tactics to drive results and achieve key performance metrics.

  • Conducts peer clinical review for medical necessity on utilization management authorization requests.

  • Provides clinical input on case management reviews working closely with the CM clinical staff.

  • Responsible for discussing review determinations with providers who request peer-to-peer conversations.

  • Participates on multiple teams to provide clinical input on medical policy reviews and development and may participate on committees that develop programs impacting clinical interventions, utilization management and case management.

  • Analyzes and uses data to guide the development and implementation of health care interventions that improve value to the member and employer.

  • Advises Health Care Services Leaders on related key performance metrics and the effectiveness of various efforts, initiatives, policies and procedures.

  • Identifies and communicates new opportunities in utilization management, provider contracting or other areas that would enhance outcomes and the reputation of the organization.

  • Provides clinical expertise and coordinates between internal clinical programs and providers of care to improve the quality and cost of care delivered to health plan members.

  • Ensures ethical decision making in compliance with contractual arrangements, regulations and legislation.

  • Supports internal communication or training that ensures service is provided to members and providers by a well-trained staff.

  • Promotes provider understanding of utilization management and quality improvement policies, procedures and standards.

  • Provides guidance and oversight for clinical operational and clinical decision-making aspects of the program.

  • Has periodic consultation with practitioners in the field and ensures that the organization has qualified clinicians accountable for decisions affecting consumers.

  • May manage staff including hiring, performance management, development and retention.

  • May participate in health plan credentialing operations and clinical aspects of the credentialing program and provider services support.

Minimum Requirements

  • Demonstrated competency working with hospitals, provider groups or integrated delivery systems to effectively manage patient care to improve outcomes.

  • Strong communication and facilitation skills with internal staff and external stakeholders, including the ability to resolve issues and seek optimal outcomes.

  • Proven ability to develop and maintain positive working relationships with community and provider partners.

  • Knowledge of the health insurance industry, state and federal regulations, provider reimbursement methods and evolving accountable care and payment models.

  • General business acumen including understanding of market dynamics, financial/budget management, data analysis and decision making.

  • Strong orientation to the application of data in managing health and quality.

  • Proven ability to develop creative strategies to accomplish goals and objectives, plan and execute complex projects and programs and drive results across internal teams and/or external partners.

  • Demonstrated ability to effectively lead and engage in a constructive manner with others.

Normally to be proficient in the competencies listed above

Senior Medical Director would have a MD or DO degree, at least 5 years clinical experience, plus at least 2 years medical utilization management and/or case management experience (prefer health insurance experience and additional MHA or MBA training), or an equivalent combination of education and experience.

Required Licenses, Certifications, Registration, Etc.

Licensed Physician with an MD or DO degree. Active, unrestricted license to practice medicine in one or more states or territories of the United States. Board Certification required. Qualification by training and experience to render clinical opinions about medical conditions, procedures and treatments under review.

#LI-Remote

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