Medical Director (Part-Time)

Central Coast Salary Range - $281,107 - $449,771

Candidates for this position must reside on the Central Coast (Ventura, Santa Barbara, San Luis Obispo, Monterey and Santa Cruz Counties) or be willing to relocate to the area upon hire. As a community-facing role, a local presence is essential to effectively engage with and serve our community. Please note that relocation assistance may be available.

Job Summary

Reporting to the Chief Medical Officer, or his/her designee, the Medical Director is responsible for providing clinical oversight for utilization, quality, care management and credentialing functions in a manner that ensures the delivery of quality, cost effective healthcare, supports organization objectives, and meets contractual and regulatory requirements. Work is varied and highly complex, and requires a moderate high degree of discretion and independent judgment. This position will focus on CenCal Health’s adult members and their service needs. This position will work a hybrid or remote schedule depending on business needs.

Duties and Responsibilities

• Provides clinical leadership for medical management functions; assists subordinate managers in resolving medical claims review, grievances, appeals, and other medical management issues.
  
• Works closely with the CMO and other medical directors to identify medical service issues that have an impact on plan benefits and their administration, develop action plans and monitor results.
  
• Identifies, analyzes, and assists in identifying quality issues and trends; makes recommendations based on findings; develops and implements agreed upon changes.
  
• Provides clinical expertise needed to effectively and efficiently resolve complex, controversial and/or unique administrative circumstances. This includes working with internal and external groups.
  
• Conducts clinical reviews and makes UM decisions for prior, concurrent (hospital/ skilled nursing facility) and retro authorizations, and appeals; approves/denies or offers medical alternatives according to CenCal Health medical review criteria; willingness to outreach to providers by phone and in person as needed; develops UM policies and procedures in coordination with Health Services staff.
  
• Works collaboratively with the Pharmacy team on clinical appropriateness of medication utilization.
  
• Establishes and maintains working relationships with providers, provider organizations and other stakeholders that support contracting, provider relations, marketing and other organizational goals and objectives.
  
• Dedicated to process improvement and organizational efficiencies.
  
• Clinical oversight and development of care management strategies and opportunities.
  
• May support population health activities.
  
• No current direct reports, the position may supervise other Health Services staff in the future.
  
• May participate in committee assignments such as Credentialing, Peer Review, Pharmacy & Therapeutics, and/or Quality Improvement as well as JOC (Joint Operating committee) meetings.
  
• Other duties as assigned, such as on-call duties related to post -stabilization care services.
  
• May participate in special projects such as those related to NCQA certification and implementation of the Medicare D-SNP line of business.