Oversees clinical direction of medical services and quality improvement functions at the health plan level. Provides medical management leadership for the health plan and, as applicable, manages all major clinical and quality program components under health plan operations. Oversees medical coordination required for effective utilization and quality management of the health plan network. Functions as medical leadership for effective care integration of WellCare pharmacy operations, utilization/case/disease Management activities, quality improvement activities, and provider relations functions.
Reports to: Medicare Executive Director
Department: State Health Services
- Collaborates with the organization's senior leadership to ensure medical compliance with all customer, regulatory, and accreditation requirements for clinical services.
- Provides current medical expertise and direction for clinical policies, procedures and programs.
- As required by business and operational priorities, establishes professional working relationships with providers and provider organizations to support the development of the highest possible provider partnerships.
- Manages day-to-day quality improvement and medical management activities.
- Establishes and is accountable for health plan utilization, OS applications and quality outcomes.
- Assures all internal and vendor medical review activities conform to company protocols, customer requirements, and professional standards.
- Ensures adherence to assigned budget accountabilities.
- Works closely with other medical directors and clinical services staff to attain and/or maintain compliance with company, customer, accreditation and regulatory requirements.
- Provides clinical expertise needed to effectively and efficiency resolve complex, controversial and/or unique administrative circumstances.
- Provides clinical guidance for sales, marketing, legal, regulatory affairs, financial, operational, and related business activities.
- As requested and needed, provides expert medical education, consultation, and supervision for the clinical staff.
- Provides medical leadership for development and attainment of the organization's goals.
- Supports provider relations and risk contracting through education, provider visits and problem resolution
- Collaborates with corporate care management to establish and implement clinical programs to support and meet care management goals
- Manages the application of all clinical aspects of the Credentialing Program, Credentialing Committee and Peer Review activities at the state level.
- Shares responsibility for quality improvement and accreditation initiatives in the assigned market(s)
- Develops value propositions for clinical programs through quantitative analytics, ROI and evidence-based data
- Initiates dialogue with providers, as necessary, to resolve differences in opinions concerning utilization management. Reviews and makes determinations regarding provider appeals.
- Ensure compliance with federal, state and NCQA standards
- Oversees provider education regarding pharmacy, utilization, quality improvement and responsible health care expenditures to improve clinical outcomes
- Establishes and maintains relationships with key stakeholders in partnership with the market leadership
- Provides medical accountability in fulfilling the company's compliance with customer audits and reports, and accreditation surveys.
- Performs other duties as assigned.
- A Doctor in Medicine (MD) or D.O. from an accredited school of medicine recognized by national medical regulatory bodies in the United States is required.
- 5 years of experience in direct patient care is required.
- Substantial experience and expertise in the development of medical policies, procedures and programs is required.
- Demonstrated success implementing utilization and quality improvement strategies /techniques and experience with physician behavior modification is required.
- Qualifications to perform clinical oversight for the services provided by the health plan to include but not limited to education, training or professional experience in medical or clinical practice is preferred.
- Past participation in a managed care UM committee is preferred.
- Ability to communicate and make recommendations to upper management.
- Ability to effectively present information and respond to questions from families, members, and providers.
- Ability to create, review and interpret treatment plans.
- Demonstrated leadership skills.
- Ability to work in a fast paced environment with changing priorities.
- Demonstrated interpersonal/verbal communication skills.
- Demonstrated organizational skills.
- Demonstrated ability to deal with confidential information.
- Ability to represent the company with external constituents.
- Demonstrated negotiation skills.
- Ability to influence internal and external constituents.
- Ability to remain calm under pressure.
- Ability to apply medical knowledge and principles to business challenges in order to achieve significant member, business, and quality outcomes.
- Ability to be detail-oriented and have a "hands-on" approach.
- Clear understanding of the managed care field and managed care operating components, with emphasis on clinical management of health services, particularly within an integrated managed care model.
- Clear understanding of regulatory systems and processes that affect managed care health system.
Licenses and Certifications:
- Doctor of Medicine (MD) required.
- An unrestricted and current license to practice medicine in the state of California (or the ability to obtain one) is required.
- Board Certification is required.