Job Abstract

The Medical Director, Medical Management, is responsible for performing and overseeing the quality assurance of the daily clinical operational functions and traditional medical management services of the organization. These consist of but not limited to prior authorization and retro review, concurrent review (hospital, Skilled Nursing Facility (SNF), Long Term Care (LTC), etc.), conducting daily hospital rounds and discharge planning, transitions of care, complex care rounds, interdisciplinary care team rounds, appeals and grievances and provider disputes. On day to day level, the Medical Director needs to work closely with the various Health Services departmental leaders and others to ensure that 1) all various day-to-day L.A. Care clinical operations are performed in a timely and regulatory compliant manner, adhering to the highest standards of evidence-based care; 2) units/programs effectiveness are met and; 3) operational processes are constantly monitored and optimized and 4) daily work performed is tracked, appropriately audited and reviewed for ongoing team education and improvement. 

This position works collaboratively with internal and external key stakeholders in providing medical leadership and clinical input for the successful delivery, improvement and development of member and provider services as well as ensure regulatory compliance as well as reduce administrative costs and burden to meet L.A. Care members’ health needs, enable providers to provide effective and quality care and achieve organizational goals and objectives. External stakeholders may include providers, medical groups, hospitals, mental health, substance use, social services providers, and regulatory organizations.

Ensure all accreditation, regulatory, clinical operational and documentation standards and reporting needs are met. 

Perform clinical review of prospective, concurrent, and retrospective reviews.

Participate in the creation of authorization rules.

Review and participate in monitoring of staff performance.

Monitor processes and ensure that team objectives are met. 

Support a culture and environment that reinforces continuously administrative efficiencies and improvements.

Serve as a clinical resource to both non-clinical and clinical staff and contracted delegates.

Participate on call coverage. 

Perform daily care management functions including care team rounds.

Review of appeals, grievances and provider disputes.

Provide strategic and operational leadership with the creation and implementation of a regional UM model.

Provide clinical and policy expertise for relevant programs, projects, vendors, new technology) and benefit reviews.

Interact and build productive and collaborative relationships with external stakeholders (i.e. medical groups, hospitals, hospitalists, community based providers and social service providers).

Manage team-specific and/or departmental projects, as assigned by leadership.

Provide input on relevant clinical services areas as it relates to public and community based communications, root cause analysis and corrective actions.

Support and interpret of relevant data and metrics.

Assist with development, review, and implementation of policies and procedures to ensure that all work of the department meets all regulatory and accrediting standards for all products. 

Chair or facilitate committees or meetings, as assigned by leadership.

Perform other duties as assigned. 

Required:
Minimum of 8 years experience in clinical practice post-residency.

Preferred:  
Prior experience in medical management or physician advisory roles 

Experience with Medicaid managed care and/or other governmental programs for underserved, safety net populations including women, children, persons with disabilities, seniors, and those of ethnic and cultural backgrounds

Experience in National Committee for Quality Assurance (NCQA) accreditation, Department of Health Care Services (DHCS) and Department of Managed Health Care (DMHC) audits.

Experience with health information technology, data analytics and process improvement.

Required:

Ability to provide leadership to physicians, nurses, and other health care professionals, and an interest and involvement in the affairs of the health care community. 

Demonstrated ability for teamwork and collaborative problem-solving.

Excellent written and verbal communication skills, negotiating skills, consensus building and teamwork, planning and implementation skills.

Knowledge with Medicare and Medicare-Medicaid.

Familiarity with Federal programs such as Medi-Cal, Medicare and Covered California.

No history of disciplinary action by State Medical Board.