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The Medical Director will play a pivotal role in leading and overseeing clinical and operational programs within NEMS MSO, with a primary focus on the Medicare Advantage line of business. This role is essential in ensuring clinical excellence, regulatory compliance, and operational efficiency. Key areas of responsibility include Utilization Management, Case Management, Quality Improvement, Risk Adjustment, and provider engagement. The Medical Director will collaborate with multidisciplinary teams, payers, and providers to improve clinical outcomes, enhance operational efficiencies, and support organizational goals.

ESSENTIAL JOB FUNCTIONS:

1. Utilization Management (UM):

• Provide clinical oversight and leadership for UM processes, ensuring timely and evidence-based medical decision-making.
• Review and approve prior authorization requests, appeals, and other medical determinations in alignment with regulatory requirements and organizational policies.
• Analyze utilization trends and identify opportunities for improving efficiency and reducing unnecessary costs.
• Collaborate with health plan partners to align UM strategies and ensure compliance with CMS, DHCS, and Medicare Advantage program requirements.

2. Case Management (CM):

• Support and guide the Case Management team in developing care plans for high-risk, high-cost patients, ensuring optimal resource utilization and improved health outcomes.
• Oversee transitions of care, ensuring seamless coordination between inpatient and outpatient settings.
• Monitor patient outcomes and implement strategies to address barriers to care for vulnerable populations.
• Evaluate the quality of case management interventions and outcomes to ensure a balance between patient-centered care, operational efficiency, and cost management, while maintaining the highest standards of clinical quality.

3. Risk Adjustment and HCC Coding:

• Collaborate with providers and coding teams to optimize accurate HCC coding and documentation.
• Lead educational initiatives to improve risk adjustment factor (RAF) scores and ensure accurate coding practices.
• Analyze risk adjustment data to identify trends and implement strategies for improvement.

4. Quality Improvement:

• Investigate and resolve member grievances related to quality-of-care issue. Collaborate with health plan partners to align QI strategies and ensure compliance with CMS, DHCS, and Medicare Plan requirements.
• Work closely with the Quality team to develop and implement clinical quality improvement initiatives.
• Monitor quality metrics (e.g., HEDIS, STAR ratings) and implement corrective actions to improve performance.
• Analyze quality data and collaborate with internal and external stakeholders to drive continuous improvement.

5. Provider Collaboration:

• Serve as a clinical resource and advisor to NEMS FQHC regarding best practices; serve as a liaison between MSO and its network providers to ensure alignment on organizational priorities and clinical goals.
• Conduct peer reviews and provide feedback to ensure compliance with clinical standards.
• Lead educational sessions, provider meetings, and collaborative efforts to enhance understanding of UM, CM, QI, and Risk Adjustment initiatives.
• Facilitate provider education on Medicare Advantage-specific requirements and quality initiatives.
• Address provider concerns and promote strong partnerships to improve patient care and operational efficiency.

6. Leadership and Strategy:

• Partner with leadership to align clinical strategies with organizational goals.
• Provide strategic input to enhance member satisfaction and clinical outcomes.
• Represent the organization in meetings with external stakeholders, including health plans and regulatory bodies.
  

7. Regulatory Compliance:

• Ensure all activities comply with Medicare Advantage regulations and CMS guidelines.
• Participate in audits and implement corrective actions as necessary.
• Stay updated on regulatory changes and industry trends affecting Medicare Advantage plans.

8. Other:

• Direct supervision of a department involving responsibility for results in terms of costs, methods and personnel. Carrying out supervisory/managerial responsibilities in accordance with the organization's policies and applicable laws. Responsibilities include interviewing and hiring of employees; planning, assigning, scheduling, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.
• Performs other job duties as required by manager/supervisor.

QUALIFICATIONS:

• Education: MD or DO degree with an active and unrestricted California medical license.
• Experience:
  • Minimum 5 years of clinical practice, with experience in managed care setting strongly preferred.
  • At least 2 years’ experience in Medicare Advantage in IPA/HMO setting.
  • Prior experience in Utilization Management, Case Management, Quality Improvement, or Risk Adjustment required.

• Certifications: Board certification in a relevant specialty. Certification in Healthcare Quality Management (CHCQM) or similar is a plus.

• Skills:
  • In-depth knowledge of Medicare Advantage regulations, risk adjustment, and HCC coding.
  • Strong knowledge of principles and practices of managed care related to utilization management and/or case management and/or discharge planning is preferred.
  • Two or more years’ direct utilization management and case management experience is preferred.
  • Excellent analytical, organizational, and communication skills.
  • Proven ability to lead cross-functional teams and collaborate with diverse stakeholders.
  • Ability to build relationships with diverse stakeholders, including providers and health plan representatives.
  • Strong presentation skills, including the ability to tailor presentations to a specific audience, and address and interact with large groups.
  • In-depth knowledge of audit, control and monitoring processes, and the ability to effectively implement and maintain them.
  • Ability to create, execute and monitor relevant strategic and business plans.

LANGUAGE:

• Must be able to fluently speak, read and write English.
• Fluency in other languages is an asset.

STATUS:

• This is an FLSA exempt position.
• This is not an OSHA high-risk position.
• This is a Full Time position.

NEMS is proud to be an Equal Opportunity Employer welcoming diversity in our workforce. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

NEMS BENEFITS: Competitive benefits, including free medical, dental and vision insurance for employee, spouse and/or children; and company contribution to 401(k).