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Medical Director
2 months ago
This position is responsible for leading a multidisciplinary team in supporting internal staff and external partners in implementing effective care management, quality, and clinical practice improvement initiatives. The successful candidate will have experience in a managed care organization or practice setting, including strong clinical practice activity.
Key Responsibilities- Develop and implement clinical programs to address member needs in partnership with the CCO Medical Directors, Senior Medical Director, and other Medical Directors.
- Implement, direct, and oversee utilization, case, disease, and quality management programs.
- Develop and implement programs for supporting participating physicians in optimizing quality management and utilization management.
- Represent the health plan in applicable activities, including medical and other professional organizations, and participate in activities that enhance the organization's image within the community.
- Provide medical support for Care Management activities.
- Provide oversight of benefit determinations and appeals for medical and pharmacy as assigned by CCO Medical Director, Senior Medical Director, or CMO.
- May partner with CCO leadership team to develop, implement, direct, and oversee programs that provide clinical strategy and interventions to CCO clinical systems.
- May plan and participate in CCO Clinical Advisory Panel (CAP) as an informal leader or member, depending on CCO/regional needs.
- Support and implement programs for network providers to share best clinical practice using population/panel management and performance data on clinical quality and utilization.
- Board-certified medical doctor or doctor of osteopathy in one of the primary care specialties, including obstetrics/gynecology (Internal Medicine, Family Practice, or Pediatrics preferred).
- Licensed physician (MD or DO) in the State of Oregon.
- Leadership experience in a managed care organization or practice setting, including strong clinical practice activity.
- Administrative graduate degree, certificate of educational achievement in medical administration, or equivalent.
- Experience working with a managed care organization.
- Medical policy knowledge and skills as related to quality, case, and disease management, credentialing activities, and utilization management.
- Clinical knowledge of the management of diverse medical problems, including impact of social concerns.
- Understanding of health equity and ways social inequities impact health.
- Basic knowledge of applicable regulatory and contractual requirements for Medicaid, Medicare, and commercial insurance.
- Understanding of managed care operations.
- Familiarity with guideline development, outcomes management, population health improvement, disease management, and cost-effectiveness and cost analysis studies.
- Awareness of physician/provider payment issues, physician practice models, and total quality and continuous quality improvement concepts.
This position may include occasional required or optional travel outside of the workplace. The employee's personal vehicle, local transit, or other means of transportation may be used.
