Medical Director, Quality & Provider Engagement

Job Summary

The Senior Director, Medical Management provides clinical and operational leadership for L.A. Care Health Plan Medical Management functions under Health Services, including Utilization Management (UM), Care Management (CM), Behavioral Health (BH), Managed Long-Term Services and Supports (MLTSS). Reporting to the Chief of Healthcare Delivery, this executive is responsible for developing and executing integrated clinical strategies that advance high-quality, cost-effective, and member-centered care while ensuring compliance with all federal, state regulations, accreditation standards, contractual obligations, and organizational policies.

The Senior Director provides oversight of core medical management functions including prior authorization, utilization review, care coordination, complex case management, transitions of care, long-term services and supports, behavioral health, population health initiatives, quality assurance, provider and delegate oversight, education and training, and clinical support for Fraud, Waste, and Abuse (FWA) prevention and investigations. Establishes strategic priorities, oversee operational and financial performance, drives system enhancements and regulatory readiness, and leads continuous improvement initiatives that enhance quality, efficiency, compliance and cost avoidance.

Works collaboratively with Medical Directors, executive leadership, providers, delegated entities, Plan Partners, community organizations, and strategic vendors. Advances an integrated, whole-person approach to care by aligning physical health, behavioral health, and long-term support services to improve member outcomes and the care experience. This position provides leadership to directors and multidisciplinary teams by fostering a culture of accountability, collaboration, innovation, and service excellence that reflects L.A. Care's mission, values, and commitment to its culturally diverse membership. The Senior Director is responsible for all aspects of talent leadership, including hiring, coaching, mentoring, performance management, staff development, and succession planning.

This position is responsible for directing all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports.

Duties

Support quality improvement efforts for the organization and promote an organizational culture of quality improvement and performance.

Develop, approve, and update medical policies, procedures, and standards of care based on current evidence-based practices.

Oversee provider facing activities relevant to Healthcare Effectiveness Data and Information Set (HEDIS), Centers for Medicare and Medicaid Services (CMS) Stars, Covered CA performance, National Committee for Quality Assurance (NCQA), and state/federal regulatory bodies, including managing provider performance measurement and reporting.

Oversee and review the delivery of patient care to ensure it meets quality standards and regulatory guidelines.

Maintain and enforce compliance with all federal and state laws, accreditation processes and standards (such as NCQA), and other regulatory requirements. Guide quality assurance and performance improvement programs and participate in quality review committees.

Support population health management and practice transformation efforts to improve quality and value of care, control total costs of care, elevate member experience of care, and advance health equity.

Work with senior leadership and network practices in deploying standardized evidence-based best practices in medicine and clinical content and ensure adoption of best practices.

Perform other duties as assigned.

Duties Continued

Education Required

Education Preferred

Experience

Required:

At least 10 years of extensive post-medical degree experience in clinical practice, quality improvement, and population health management.

Proven experience in a physician leadership role, including managing teams.

Preferred:

Minimum of 5 years of clinical experience with direct patient care.

At least 5 years of experience with credentialing, peer review, or provider performance improvement.

Informatics and Analytic experience with quality data from multiple disparate sources, including but not limited to 834, 837, 278 EDI and HIE HL7.

Skills

Required:

Must have a passion to improve quality for vulnerable populations.

Strong leadership presence with the ability to lead, mentor, and motivate a team.

Ability to think strategically and take a broad, business-oriented perspective.

Strong analytical and problem-solving skills, with a data-driven approach to evaluating programs.

Exceptional communication and presentation skills to effectively convey complex medical concepts to diverse audiences.

Ability to review and assess clinical cases for potential quality issues and legal cases for assessment of severity and actions necessary.

Must maintain current competency in provider quality regulations and standards.

Capacity to work in a fast-paced, dynamic, and often ambiguous environment.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information