Senior Medical Director - Sharp Health Plan

Hours: Shift Start Time: 8 AM
Shift End Time: 5 PM
AWS Hours Requirement: 8/40 - 8 Hour Shift
Additional Shift Information: Weekend Requirements: No Weekends
On-Call Required: No
Hourly Pay Range (Minimum - Midpoint - Maximum): $130.140 - $167.923 - $205.705
The stated pay scale reflects the range that Sharp reasonably expects to pay for this position.
The actual pay rate and pay grade for this position will depend on various factors, including an applicant's years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.
What You Will Do This Senior Medical Director position provides critical management and oversight for Sharp Health Plan's (SHP) physicians (Medical Directors (both medical and behavioral health) and the Physician Reviewers) to coordinate the necessary co-management of our members related to their medical, behavioral health and pharmacy needs.
This position also provides the physician cohesive collaboration necessary for the continuum of care foundation for our NCQA required population health management program.
Additionally, this position provides the representation of physician's insight, perspective and leadership on the Health Services Management team and the other strategic and operational leadership, projects and meetings throughout the SHP.
This position oversees all physician management and medical care for all of Sharp Health Plan products (Commercial, Exchange, Medicare, POS/PPO) services, and oversees the health care needs of the membership.
Serves as a lead medical manager and policy advisor to SHP clinical and its Chief Medical Officer.
Required Qualifications Doctor of Medicine (MD) - Internal Medicine or Family PracticeOR Doctor of Osteopathic Medicine (DO) - Internal Medicine or Family Practice.15 or more years of clinical practice of medicine.5 years' experience as an HMO Health Plan Medical Director.California Physicians and Surgeons License - Medical Board of CA - REQUIREDOther Qualification Requirements Unrestricted CA MD/DO license required.Essential Functions Provides critical management and oversight for the Plan's physicians (Medical Directors (both medical and behavioral health) and the Physician Reviewers) to coordinate the necessary co-management of our members related to their medical, behavioral health and pharmacy needs.Responsible and accountable to the Chief Medical Officer for managing health plan medical costs and assuring appropriate health care delivery for SHP's products and services.Provides representation of physician's insight, perspective, and leadership on the Health Services Management team and other strategic and operational leadership projects.Works collaboratively with other plan functions that interface with medical management such as provider relations, member services, benefits and claims management, IT management, etc.Plans, organizes, and directs the professional medical services program, consisting of all primary and specialty services for in-patient, out-patient, preventive and wellness programs.Develops and implements health plan clinical policies, goals, and objectives.Provides professional leadership and direction to the functions within the Medical Management Department.Develops and updates Physician management department work plan.Responsible for and assists with the development of staffing plans and assuring the adequate allocation of resources to the medical management functions.Responsible and accountable for implementing the Utilization/Cost Management Program and Quality Improvement Program.Oversees and mentors Medical Directors and Physician Reviewers.Actively engages with SHC leaders in Physician Experience Council, Physician Leadership Academy, and other key physician leaders to promote quality of care.Assists the Chief Medical Officer with activities to promote positive community relations.Assures plan conformance with legal and regulatory requirements.Assists CMO in continued builds strong partnerships with Medical Director PMGs and their clinical teams.Assists CMO in the implementation of NCQA top decile improvement programs and work plans.Assists the Chief Medical Officer and Quality Improvement Director in creating and maintaining a system that gives feedback to providers regarding managed care effectiveness.Assists the Chief Medical Officer in designing and implementing corrective action plans to address issues and improve plan and network managed care performance.Collaborates with Chief Medical Officer in creating and maintaining programs that incentivize providers to achieve selected utilization/cost and quality outcomes.Participates in policy review, performs analysis, and makes recommendations for updating current policies to meet accreditation and regulatory requirements.Ensures newly updated EHB's are implemented into policies.Participates in the retrospective review and analysis of Plan performance from summary data.Achieves and maintains benchmarked utilization and cost management goals and clinical quality improvement objectives.Provides periodic written and verbal reports and updates as required.Supports NCQA survey activities and prepares for site visits.Supports pre-admission review, utilization management, and concurrent and retrospective review processes.Oversees A/G and UM reviews of all clinical reviewers.Participates in risk management reviews.Assists in pharmacy utilization management, catastrophic case review, outreach programs, HEDIS reporting, and site visit review coordination.Conducts quality improvement and outcomes studies as directed.Assists in POS/PPO Case Management and high-cost review.Co-Chairs with the CMO CPTAC and Peer Review Committees.Partners with Senior Management including CMO and COO for ongoing requests for statements and reviews.Participates in the grievance process with the Chief Medical Officer.Monitors member and provider satisfaction survey results and implements changes as needed.Participates in SHP Advisory Committees.Participates in key marketing activities and presentations, as requested.Promotes wellness and ensures programs of prevention, education, and outreach to members and providers are consistent with SHP's mission, vision, and values.Maintains up-to-date knowledge of new information and technologies in medicine.Performs and oversees in-service staff training and education of professional staff.Represents SHP at medical group meetings and conferences.Participates in the development of strategic planning for existing and expanding business.Recommends changes in program content in concurrence with changing markets and technologies.Ensures that the Utilization Management staff is available on a 24-hour basis.Performs other duties as requested or assigned.Collaborates with the Director of PHM/Medical Management to guide and direct staff in relation to medical issues.Completes and/or supervises the completion of all clinical appeals and grievances.Supervises Physician Reviewer(s) and Medical Directors including Behavioral Health Medical Directors.Assists in the development and interpretation of the covered benefit provisions of member materials and Plan contracts.Knowledge, Skills, and Abilities Strong clinical background and skills.Solid understanding of utilization management and quality assurance activities.Excellent communication skills, both verbal and written.Strong interpersonal skills, including the ability to interface effectively with employees, members, physicians, senior management, and the public.Management skills to meet the organizational goals.Knowledge of regulatory and accreditation agencies and requirements.Able to manage multiple priorities and deadlines in an expedient and decisive manner.Able to manage difficult peer situations arising from medical care review.Appreciation of cultural diversity and sensitivity towards target population.Demonstrates commitment to the organization, co-workers, and subordinates.Sharp HealthCare is an equal opportunity/affirmative action employer.
All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class.

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