Medical Director

San Francisco Health Plan is committed to providing high-quality care for low-income San Franciscans and supporting the provider safety net. We leverage our resources to support the triple aim: improved population health, improved quality of care, and improved affordability. The Medical Director is the Plan's primary UM physician conducting concurrent and prior authorization case reviews. You will be the health plan physician lead on the Health Homes program and the San Francisco Safety Net Pain workgroup, and provide physician consultative expertise to the health services department: clinical operations (UM: inpatient and outpatient, and discharge transition planning), health improvement (HEDIS, practice improvement, disease management, member grievance reviews, IT systems that support department functions, and member incentives) and pharmacy (including PGY 1 pharmacy residency and medication therapy management program). You will play an important role with key health plan initiatives, such as the implementation of a care management system designed to improve coordination of care and achieve better clinical outcomes, creating clinical criteria, and evaluating UM strategies to improve efficiency.

Salary range: $241,950 - $288,750

WHAT YOU WILL DO:

Leadership

• Provide primary leadership of SFHP's program which serves at risk and medically complex members as defined by internal risk stratification and health plan mandate (e.g. Health Homes)..
• Provide SFHP clinical leadership of the San Francisco Safety Net Pain Management workgroup.
  

Clinical Decision Making and Support Utilization Management

• Provide clinical guidance on medical necessity and transfer decisions to support UM staff. Responsibilities include contacting attending and ED physicians to discuss patients.
• Share responsibility for utilization management and pharmacy decisions: determining medical necessity based on established criteria, interpreting benefits and limitations, and consulting with providers.
• Participate in Utilization Management Committee.
• Call physicians at their discretion to discuss management of members related to pharmacy and UM authorizations, inpatient care, and high-dose pain management focusing on evidence, best practices, and medical necessity.
  

Quality

• Investigate and resolves potential quality incidents and determines their appropriateness for review by the Physician Advisory Committee.
• Review appeals and provides second opinions regarding medical necessity
• Review clinical grievances and is an active participant in Grievance Review Committee
• Provide clinical input for programs
  

Pharmacy

• Participate in formulary criteria development
  

Utilization Management

• Helps develop and revise policies to support utilization management activities, including criteria and guidelines for appropriate use of services, clinical practice guidelines, and treatment guidelines
  

Clinical Quality

• Provide clinical support for program development of disease management and practice improvement.
• May serve on Quality Improvement Committee, Pharmacy and Therapeutics Committee, or the Practice Improvement Program Advisory Group.
• Represent SFHP with our external community partners, including giving presentations related to SFHP priorities.
• Lead special project and assignment as requested by the Sr. Medical Director and Chief Medical Officer.
• Provide clinical guidance related to systems implementations (such as care management IT integration systems)
  

WHAT YOU WILL BRING:

• MD/DO degree from an accredited program, with active, unrestricted California medical license. Board certified required.
• A current CA license to practice without restriction.
• 5+ years of clinical experience.
• Previous managed care experience preferred.
• Experience and facility with health information technology and clinical data analysis.
• Experience in managing challenging conversations with professional peers related to medical case review; supportive of managed care strategies.
  

WHAT WE OFFER:

• Health Benefits
  
  • Medical: You'll have a choice of medical plans, including options from Kaiser and Blue Shield of California, heavily subsidized by SFHP.
  • Dental: You'll have a choice of a basic dental plan or an enhanced dental plan which includes orthodontic coverage.
  • Vision: Employee vision care coverage is available through Vision Service Plan (VSP).
    
  
  
• Retirement - Employer-matched CalPERS Pension and 401(a) plans, 457 Plan.
• Time off - 23 days of Paid Time Off (PTO) and 13 paid holidays.
• Professional development: Opportunities for tuition reimbursement, professional license/membership.
  

ABOUT SFHP:

Established in 1997, San Francisco Health Plan (SFHP) is an award-winning, managed care health plan whose mission is to provide affordable health care coverage to the underserved low and moderate-income residents in San Francisco County. SFHP is chosen by eight out of every ten San Francisco Medi-Cal managed care enrollees and its 175,000+ members have access to a full spectrum of medical services including preventive care, specialty care, hospitalization, prescription drugs, and family planning services.

San Francisco Health Plan is proud to be an equal opportunity employer. We are committed to a work environment that supports, inspires, and respects all individuals and in which our people processes are applied without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic origin, military service status, citizenship, or other protected characteristics.

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

San Francisco Health Plan is an E-Verify participating employer.

Hiring priority will be given to candidates residing in the San Francisco Bay Area and California.

#LI-Hybrid

(Hybrid remote/in-office)

PI279823291