Sr. Medical Director
Chief Medical Officer
Established in 1996, Prospect Medical Holdings, Inc. has grown into a significant provider of coordinated regional healthcare services in Southern California, Connecticut, New Jersey, Pennsylvania, Rhode Island and South-Central Texas. We are hospitals and affiliated medical groups working for the benefit of every person who comes to us for care. Our comprehensive networks aim to provide coordinated, personalized care. We specialize in building comprehensive networks of quality healthcare services designed to meet the needs of our patients and members. Our goal is always to ensure high-quality outcomes. The Sr. Medical Director will be seated at CharterCARE Health Partners in Providence, RI. We are a coordinated regional care network comprised of two acute care hospitals, a large nursing home facility, a regional cancer center, a rehabilitation center, a community primary care center, a home health services company, an IPA, and a large physician group practice. CharterCARE also operates a school of nursing. Our coordinated regional care model allows us to deliver services to patients at multiple levels of care, at the right time and place and at lower costs. This way of organizing and delivering health care services enables us to optimize population health management strategies in Rhode Island. CharterCARE is a joint venture company that leverages both the health care management expertise and capital strength of Prospect Medical Holdings, a California-based company that owns and operates hospitals in Texas and California.
The Senior Medical Director will report to the National Chief Medical Officer of our MSO, Prospect Medical Systems, and have direct administrative oversight of the medical components of state wide managed care clinical operations including Prospect Northeast ACO and Prospect Rhode Island IPA. The Senior Medical Director will oversee Utilization Management, Case Management, and Quality Improvement for the region and have 2 direct reports with the possibility of more depending on growth. The Senior Medical Director will ensure Prospect Medical Systems in Rhode Island meets or exceeds the highest standards of value-based care with the goals of the “Quadruple Aim”.
Oversee the Concurrent Review Process. Meet with case managers on daily basis to discuss all members admitted to an acute care facility to ensure that appropriate case management and discharge planning is implemented and facilitate the member’s transition to the outpatient setting. Accountable for Inpatient bed day management with a focus on utilization metrics (Admission rate, ALOS, Readmission Rates, ER rate, etc.) Collaborate with designated hospitalist teams to ensure appropriate coverage at all facilities, appropriate and efficient management of all patients in the inpatient setting, and appropriate discharge planning for the post-acute transition period.
Work with the Director of Health Services to provide oversight of the Case Management Department. Review open cases regularly. Monitor and lead Case Managers for SNP and Complex Case Management. Work with PCMH practices to ensure that goals are achieved as it relates to member satisfaction, NCQA guidelines, utilization metrics, high quality care and cost effectiveness.
Oversee the Skilled Facility Department. Review all cases in house regularly with oversight and responsibility for admits, length of stay (LOS), re-directs, transition of care, re-admits conducting regular meetings with hospitalists/SNFists/case managers. Documents all data in useable format.
Provide physician oversight of the Utilization Management and Prior Authorization process to ensure the delivery of cost effective, high quality, and appropriate medical care as needed. This includes adherence to Prospect’s denial process and compliance with industry standards and denial ratios.
Work with all aspects of medical management to ensure compliance with outside regulatory standards.
Work with the Quality Improvement Committee and the Quality Improvement Department to develop standards of care for all participating providers. Review data pertinent to the Quality Program (such as site audit and medical record audits, complaints and grievances) to ensure that the standards are being met. Refer quality issues as they are identified to the Quality Improvement Department and Committee for appropriate action.
Facilitate compliance with those quality care and quality service measures implemented from time to time, by both Executive Management and contracted Payor groups, to ensure member satisfaction and quality care (i.e. pay for performance programs, member satisfaction surveys, utilization profiling, HCC coding.)
Participate in the Credentialing Process as outlined in the Prospect Credentialing Policies and Procedures.
Develop and/or implement provider performance scorecards and incentive programs. Oversees provider network adequacy and credentialing.
Responsible for all medical aspects of the health care delivery system implemented by the organization for those IPA divisions assigned and/or for those IPA’s where coverage is necessary.
Act as the physician liaison between the organization, network providers, health plans, regulatory agencies, and other customers of the organization. Confers and consults with participating and non-participating health professionals or providers with questions related to the Utilization Management process.
Participates in retrospective medical review.
Assists in audits, as needed.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. This job description reflects management's assignment of essential functions; it does not prescribe or restrict the tasks that may be assigned. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Must possess a valid Rhode Island medical license to practice without restrictions.
Must be Board Certified in a specialty recognized by ABMS.
Minimum 5 years clinical experience.
Prior experience in medical administration, utilization review and quality management.
Prior experience in a managed care environment
Maintains member confidence and protects operations by keeping claim information confidential in compliance with HIPAA requirements.