Medical Director (Covered California)

Position Summary/Position

Under the direction of the Senior Medical Director, the Medical Director provides clinical leadership and guidance towards quality improvement activities aimed at achieving the strategic initiatives set forth by Plan administration. The Medical Director is also responsible for clinical oversight and management of all IEHP utilization management activities and provides physician level guidance in quality management and care management departments. The Medical Director also supports all departments in meeting the regulatory requirements set forth by the various government agencies.

Major Functions (Duties and Responsibilities)

1. Develop and implement medical policy for utilization management activities and functions, including benefit manual statement, policies and procedures, and Utilization Management Subcommittee Guidelines. Provide training and consultation for both internal staff and medical personnel of the Plan regarding policy application.
2. Provide direction and control of current medical practices ensuring that medical personnel of the Plan follow medical protocols and rules of conduct.
3. Ensure assigned patients are provided healthcare services and necessary medical attention at all locations.
4. Collaborates with Contracting Department to ensure full and appropriate primary, specialty, and ancillary care network adequacy for Members.
5. Ensures that medical decisions are rendered by qualified medical personnel, unhindered by fiscal or administrative management. Provides clinical oversight and direction over credentialing process.
6. Ensures that medical care rendered by providers meets with applicable professional standards for acceptable medical care and quality.
7. Consults on written medical protocol for Plan physicians to ensure adherence to current standards and quality of medical care.  Coordinates professional interactions among practitioners and lends assistance toward correcting any deviation from medical standards.
8. Interacts regularly with inpatient hospitalist groups, PCP & specialists to ensure appropriate medical care is provided and utilization standards are met.
9. Develops and manages a formal Utilization Management Program for the Plan and its Providers. This Program includes protocol, procedures, oversight, and training in the following areas:
   a. Provider Selection
   b. Credentialing
   c. Peer Review Activities
   d. Referral Management
   e. Pre-admission authorization
    f. Prospective, concurrent, and retrospective review
   g. Utilization review reporting and evaluation
   h. Case Management
   i. Provider Incentive Programs
  j. Chairperson/ Co-Chair of the HEDIS Improvement Committee, Quality Management Committee, Quality Improvement Committee, Credentialing Committee, Grievance Trend Committee
   k. Participates on the Pharmacy and Therapeutics Subcommittee
   l. NCQA Accreditation.
10. Act as a liaison to Provider Relations as a link between IEHP and individual physician, IPA’s, medical groups, and hospitals.
11. Adjudicate medically related grievances and appeals that flow through the Member grievance and appeals process.
12. Review State mandated benefits to ensure IEHP is in full compliance through its Providers.
13. Assist Compliance on sanctioned and excluded Provider management. Responsibilities include oversight of safe transitions of care for Members and communication with regulatory agencies and impacted departments (e.g., Pharmacy, Claims, Care Management, Utilization Management, etc.).
14. Provide physician level guidance on organizational improvement initiatives, including LEAN activities and Process Improvement Team projects.

Major Functions (Duties and Responsibilities) Cont

Supervisory Responsibilities

Experience Qualifications

Five (5) years or more of post-residency experience in a recognized medical specialty, which must have included at least one (1) year of medical leadership experience.

For Covered California Candidates - Three (3) years of experience with Covered California or other commercial Healthcare products.

Preferred Experience

Medical Director for an IPA, medical group, or HMO highly desirable. Utilization management experience is a plus. Primary Care Physician in internal medicine, family practice or pediatrics preferred.

Education Qualifications

Doctorate of Medicine from an accredited institution required.

Preferred Education

Professional Certification

Certification by one (1) of the American Specialty Boards.

Professional Licenses

Possession of an active, unrestricted, and unencumbered Physician’s and Surgeon’s license issued by the State of California Medical Board required. 

(A physician certified in a state other than California may be employed prior to receipt of a California license provided that an application for a California physician and surgeon’s license is filed in the state of California prior to date of appointment.)

Primary Care Physician in internal medicine, family practice or pediatrics preferred.

Drivers License Required

Knowledge Requirement

Strong knowledge of medical and CMS regulations. 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; and overview of the highly specialized techniques, procedures, and equipment used in the medical or surgical specialties.)

Skills Requirement

Microcomputer applications such as Microsoft Office, Word, Excel, and Access helpful.

Abilities Requirement

Commitment to Team Culture

The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.

Working Conditions

While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools, or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; and taste or smell. The employee must occasionally lift or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus.

Position is eligible for telecommuting/remote work location upon completing the necessary steps and receiving HR approval. All IEHP positions approved for telecommute or hybrid work locations may periodically be required to report to IEHP’s main campus for mandatory in-person meetings or for other business needs as determined by IEHP leadership.

Work Model Location

Physical Requirements