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Senior Medical Director, Utilization and Care Management Services

Job Category:  Clinical
Department:  Health Services
Location: 

Los Angeles, CA, US, 90017

Position Type:  Full Time
Requisition ID:  8341

 

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.

Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.

As a condition of employment, L.A. Care requires a COVID-19 vaccine. This requirement includes our remote workforce. If you would like to request an exemption, L.A. Care has implemented a process to consider exemptions, for documented medical conditions and sincerely held religious beliefs. L.A. Care will review all exemption requests prior to proceeding with the recruitment process.

Job Summary

The Senior Medical Director will be assigned a geographic region in L.A. County and report to the Deputy Chief Medical Officer in planning, organizing, directing and developing our new regional network medical management (utilization and care management) model.   Leading and working with a multi-disciplinary team, he/she is expected to execute L.A. Care Health Services’ programs and strategic vision.  The Senior Medical Director also is expected to ensure that the administrative functions related to utilization management (UM) are performed in a clinically appropriate and compliant manner.  The administrative functions include performance of prospective, concurrent and retrospective utilization review, provider appeals and disputes and member grievances.  On the care management (CM) side, the Senior Medical Director is expected to work with and support UM and CM staff on transition of care and community based care management needs.  Additionally, on day to day level, the Senior Medical Director needs to work closely with the various Health Services departmental directors and others to ensure that 1) day-to-day L.A. Care clinical administrative operations are performed in a timely and compliant manner; 2) units/programs effectiveness are met and; 3) operational processes are constantly monitored and improved.

 

On a regular basis, the Senior Medical Director also needs to interact and have a productive working relationships with various external stakeholders.  The external stakeholders include contracted and non-contracted providers, medical groups, hospitals, mental health, substance use and social services providers in their region to improve member and providers service, 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.  

Duties

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

 

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

 

Support care management rounds.

 

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 .

 

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

 

Support and optimize regional population health interventions in the assigned regions.

 

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

Education Required

Doctor of Medicine (M.D.)

Education Preferred

Master's Degree

Experience

Required:
Minimum of 10 years relevant Health Care experience with at least 5 years relevant Health Plan and/or administrative, and experience in a Medicaid/Medi-cal and/or Medicare population.

 

Minimum of 10 years of supervisory/management experience.

Preferred:  
Experience in developing both utilization, care management programs (i.e. transition of care services) .


Knowledge with Medicare and Medicare-Medicaid.

 
Experience with working with licensed and non-licensed providers (i.e. community health workers, counselors etc.).


Experience in NCQA accreditation, DHCS and DMHC audits.


Demonstrated experience with HEDIS, CMS Star relating.


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 collaborate with key stakeholders 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.

Licenses/Certifications Required

Physician License to practice in California - active, current and unrestricted California License
Board Certified, preferably in a primary or medical specialty - Active, current and unrestricted California license.
Certified/Qualified to provide Clinical Supervision hours.

Licenses/Certifications Preferred

Required Training

Additional Information

No history of disciplinary action by State Medical Board

 

L.A. Care offers a wide range of benefits including

  • Paid Time Off (PTO)
  • Tuition Reimbursement
  • Retirement Plans
  • Medical, Dental and Vision
  • Wellness Program
  • Volunteer Time Off (VTO)

 

At L.A. Care, we value our team members’ safety. In order to keep our work locations safe, each employee is required to self-screen for symptoms prior to entering any L.A. Care location each day. L.A. Care and all of its staff are required to comply with all state and local masking orders. Therefore, when on-site at any L.A. Care location, employees are expected to wear a mask in areas where physical distancing cannot be managed.


Nearest Major Market: Los Angeles

Job Segment: Medicare, Medicaid, Social Services, Public Health, Counseling, Healthcare, Service

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