Senior Medical Director

Job Summary

The Senior Medical Director will provide medical leadership and support the Chief Medical Officer (CMO) to ensure medical quality and adherence to professional and ethical standards by the plan and its network of providers.

The Sr. Medical Director will oversee and manage all clinical activities for CenCal members, focusing on quality, operational efficiency, and strategic planning for quality, utilization, and care management programs. This role provides physician and clinical leadership for Utilization Management and Quality initiatives, Case Management initiatives, and planning in collaboration with department leaders. The Sr. Medical Director will also engage in external provider relations, including education, outreach, and program development. The position also provides senior clinical leadership to the appeals, grievances, and quality of care concerns processes.

Duties and Responsibilities

• Serve as a key senior leadership team member, actively participating in strategic and operating plan efforts.

• Develop and execute strategic and operating plans, including analysis, detailed plans, budgets, and success metrics.

• Develop, implement, manage, and enhance integrated care management and care coordination services, especially for high-risk/high-cost members.

• Develop and monitor clinical programs that support care management and care coordination services.

• Ensure the timely use of Utilization Management (UM) criteria and guidelines in member treatment.

• Develop medical policies and clinical programs that support CenCal's mission and community objectives.

• Provide specialized knowledge and support for chronic co-morbid condition management, care integration, transitions, and referral management.

• Oversee the development and improvement of data collection and analytics capabilities.

• Assist Case and Utilization Review Managers in identifying and implementing appropriate services for individualized care plans.

• Provide physician/clinical leadership for quality initiatives, including care management, substance abuse projects, and integrated behavioral health services.

• Stay current with state and federal mandates and benefits to ensure full compliance with CenCal Health Services, including oversight of delegated entities/providers.

• Comply with all CenCal Health safety requirements.

• Ensure appropriate confidentiality of data and findings.

• Communicate job expectations, plan, monitor, and appraise job results. Coach, counsel, implement corrective action when necessary, and promptly complete performance evaluations.

• Develop strong relationships with key stakeholders, including providers, clients, vendors, and other Health Plan organizations.

• Achieve tactical and strategic medical quality targets and utilization goals.

• Provide creative direction to enhance operational and medical care delivery efficiencies.

• Collaborate with executives responsible for affiliate strategic and operating initiatives in medical-related operations, focusing on quality of care and effective cost management.

• Foster a leadership climate contributing to a highly engaged and diverse workforce committed to CenCal's Vision, Mission, and Values.

• Develop and mentor CenCal's medical management team and related clinical management/staff.

• Maintain a visible leadership role in civic, professional, and industry-related organizations.

• Develop and maintain departmental operational and service policies and procedures aligned with company objectives.

• Lead innovative programs and special projects to reduce administrative burdens, improve quality of care, and enhance provider and member satisfaction.

• Develop and maintain a working knowledge of electronic health records to enhance quality, documentation, and reporting.

• Perform other duties as assigned, adhering to all CenCal Health employee policies and procedures.

Qualifications

Knowledge/Skills/Abilities

• In-depth knowledge of Managed health care, the HMO history, and the regulatory environment of managed care

• Understanding of administrative practices and procedures, including but not limited to quality assessment and improvement, utilization review, peer review, credentialing and risk management, rules, regulations, policies and standards related to managed care, principles of effective supervision and organization, methods, techniques, practices, principles, and literature in the broad field of medical sciences.

• Familiarity with regulatory and accreditation standards (e.g., NCQA, CMS).

• Proven leadership skills with the ability to lead and inspire clinical teams.

• Effective in developing and implementing strategic plans to improve clinical and operational outcomes.

• Exceptional verbal and written communication skills.

• Ability to communicate complex clinical and operational information to various stakeholders, including healthcare providers, administrative staff, and regulatory bodies.

• Strong analytical and problem-solving skills.

• Ability to analyze clinical data to drive quality improvement and operational efficiency.

• Excellent decision-making skills, with the ability to make informed and timely clinical and administrative decisions.

• Capacity to handle complex clinical situations and provide guidance on best practices.

• Ability to work collaboratively with multidisciplinary teams, including physicians, nurses, administrative staff, and external providers.

• Skilled in building and maintaining relationships with external providers and stakeholders.

• Ability to develop and implement strategic initiatives to improve clinical quality and operational performance.

• Ability to mentor and develop clinical staff, fostering a culture of continuous learning and improvement.

• Experience in providing training and education to healthcare providers and staff.

• Ability to adapt to changing healthcare environments and regulatory landscapes.

• Flexibility to manage multiple priorities and projects simultaneously.

Competencies

• Management Administration Skills: Manages and/or facilitates employees, budgets, and equipment assigned to them while helping employees clearly understand their roles and responsibilities to achieve organizational objectives. Helps develop employee performance by delegating responsibilities and providing accurate feedback and timely assessments.

• Leadership Skills: Able to assume a role of formal or informal authority as necessary; advocate new ideas, even when risk is involved; delegate responsibility and empower associates to make decisions; capable of providing constructive feedback to others; able to receive constructive feedback from others; makes personal commitment to mentor and grow others.

• Strategic Thinking: Formulates objectives and priorities and implements plans consistent with the organization's long-term interest in a global environment, Capitalizes on opportunities, and manages risks.

• Communication Skills-Oral, Listening, & Written: Communicates both verbally & in writing in such a manner that it is easy to understand and interpret what and why information is being communicated. Listens attentively without interrupting and/or being distracted by other things.

• Collaboration & Teamwork: Utilizes communication techniques and methods that generate trust, collaboration, open two-way communication, and a supportive work environment. Develops and generates team momentum, enthusiasm, and camaraderie to obtain maximum team performance. Values team members' diverse talents and works to include various points of view in decision-making.

• Human Capital Management: Builds and manages workforce based on organizational goals, budget considerations, and staffing needs. Ensures employees are appropriately recruited, selected, appraised, and rewarded; takes action to address performance problems. Manages a multi-sector workforce and a variety of work situations.

• Conflict Management: Encourages creative tension and differences of opinions. Anticipates and takes steps to prevent counter-productive confrontations. Manages and resolves conflicts and disagreements constructively.

• Decisiveness: The ability to make difficult decisions promptly.

• Walk the Talk: Do what you say you are going to do. Be accountable for your actions.

• World-class mindset: Behaves honestly, fairly, and ethically. Shows consistency in words and actions. Models high standards of ethics. Punctual and exhibits professional email etiquette. Adheres to company and department standards. Committed to excellence.

Education and Experience

• Medical Degree (MD or DO) with an active, unrestricted license to practice medicine by the Medical Board of California

• Board Certification in a medical specialty recognized by the American Board of Medical Specialties

• Five (5) years of post-residency/training experience. At least five (5) years of medical administrative experience

• Five Ten (5-10) years experience with Medi-Cal managed care and/or Medicare.

• Managed Care experience, such as Utilization Management experience for an IPA, medical group, or HMO, is highly desirable.