Senior Medical Director, Medical Management

Job Summary

The Senior Medical Director, Medical Management is a key medical leadership role responsible for providing and overseeing the delivery and quality assurance of traditional medical management services and functions. Leading and working with a multi-disciplinary team, executes L.A. Care Health Services’ programs and strategic vision and ensure that both the administrative and clinical functions related to medical management are performed in a clinically appropriate, evidence-based and compliant manner.  These functions consist of but are not limited to utilization management, appeals and grievances, provider disputes, care management, long term care services, program design and regulatory reporting along with oversight, support and relationship management within both our direct network, delegated medical groups and provider network.  The Senior Medical Director will develop a common clinical framework on how the clinical staff conceptualizes and defines care and disease state management to drive consistency and accuracy in making all medical management decisions. 

Duties

Works primarily within the health services departments of utilization management, care management and long term care services.  Accountable for the medical management, reporting and analysis to identify opportunities for improvement and evaluation of interventions and programs; including planning, directing, implementing and supervising medical management activities. Applies clinical skills in order to establish and maintain systems for managing medical management, including the use of evidence based criteria in clinical decision making. Serves as the physician leader in the organization, liaisons cross functionally with other departments such as contracting, network, data analytics, delegation oversight , claims and configuration and interface with both delegated entities and providers in the network..

Develops, mentors, and coaches Medical Management interdisciplinary care teams that  may include nurses, physicians, social workers, care coordinators, pharmacists and behavioral health.  Supports internal and external medical management teams with excellent clinical skills and expertise and ensures that the clinical decision making process meets regulatory requirements in a timely, equitable and fair manner.  Establishes and supports staff and systems for managing utilization, including the development and use of evidence based criteria. Helps design and manages special projects and help lead efforts in the redesign of Medical Management, training, delegation and oversight, behavioral health. 

Performs medical reviews and determinations (i.e. brief written criteria/reasons for determination) on Utilization Management and Pharmacy, prior authorizations, concurrent, retrospective authorizations, grievance and appeals, and State Fair Hearings for L.A. Care Health Plan's direct lines of business.  

Develops and implements departmental policies and procedures, desk procedures and workflows; Ensure integration of quality for the Model of Care program and related reporting and monitoring. 

Develops and maintains departmental statistical and performance reports; Develops, implements and monitors performance standards.

Duties Continued

Provide clinical direction and oversight of both direct and delegated medical management functions consistent with regulatory requirements.

Supervises  a team of physicians involved in all medical management function.  Develops goals, objectives and actions plans for assigned staff which includes full management responsibility for the hiring, performance reviews, salary reviews and disciplinary matters for direct reporting employees. 

Develops and implements critical clinical strategies in areas such as  in-patient management and discharge planning, transitions of care, out of network/out-of-area coordination, network development and optimization, provider engagement and joint operating meetings.

Strengthens collaboration and partnerships with key providers organizations (Planned Partners, Hospitals, Participating Provider Groups, Federally Qualified Health Centers, and the L.A. County Department of Health Care Services), and will also serve as the spokesperson and liaison for L.A. Care medical management. Conducts on-site visits with providers (medical groups, Independent Practice (or Physician) Association (IPA), hospitals, plan partner representatives) and key community agency partners; attend scheduled Joint Operating Meetings (JOMs). Chairs the appropriate medical management committees and other committees and task forces as assign.

Oversee data analytics, including evaluation, process, and outcome reporting for Clinical Provider Services

Prepares briefings, reports, consultation documents and presentations that clearly articulate LA Care's  regulatory position and policy.  Develop regulatory position and policy based on research and evidence.

Engaging with providers, including facility, professional and ancillary, along with independent physician associations (IPAs) / provider physician groups (PPGs).  The Senior Medical Director will work across departments and with external entities as well as support external department leaders in overseeing the services delegated to external partners.  

Perform other duties as assigned.

Education Required

Education Preferred

Experience

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

Minimum 3 years of experience in medical management, managed care or physician advisory services. 

Minimum of 10 years of experience with Lead/Supervisory/Management responsibilities.

Experience in maintaining liaison with Federal, State, and local bodies and medical organizations.

Experience in performance management and possession of strong analytic ability. 

Preferred:  
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.

Skills

Required:
Ability to lead by influence and build strong internal and external relationships is critical to the success of this position.

Evidence of being able 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. 

Ability to build key relationships with and support our external network providers including facilities, primary and specialty care providers and ancillary service providers.

Ability to collaborate with key internal stakeholders and department leaders across the organization with a cohesive approach to producing the highest quality outcomes, while having an agile approach to innovate.

Evidence of ability to provide leadership in the medical profession, and an interest and involvement in the affairs of the health care community.

Other important qualities include excellent written and verbal communication skills, negotiating skills, consensus building and teamwork, planning and implementation skills.

Excellent communication skills, negotiating skills, consensus building, analytic ability, planning and implementation skills.

Excellent problem solving, planning, and organizational skills.

Knowledge with Medicare and Medicare-Medicaid.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Additional Information