Medical Director

The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.

What You Will Be Doing:

The Medical Director is responsible for providing clinical oversight of the Health Plan’s utilization, quality, pharmacy, and credentialing and health equity functions in a manner that ensures the delivery of quality, cost effective healthcare, supports organization objectives, and meets contractual, accreditation and regulatory requirements. The position supports the grievances and appeals team with clinical oversight of grievances and quality of care investigations and resolutions. Work is varied and highly complex and requires a moderate to high degree of discretion and independent judgment.

Our Vision:

Continuously improve the health of our community.

Our Mission:

We provide healthcare value and advance wellness through community partnerships.

Essential Functions:

• 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 to identify medical service issues that have an impact on plan benefits and their administration, develop action plans and monitor results.
• Identifies and analyzes and assists in identifying and analyzing care and 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.
• Conducts clinical reviews and makes UM decisions for prior, concurrent, and retro authorizations, and appeals; approves/denies or offers medical alternatives according to HPSJ’s medical review criteria.
• Conducts reviews of grievances and quality of care issues, identifies opportunities for improvement and works with both internal and external stakeholders to improve care and services.
• Provides expertise and guidance for activities related to improving quality and health equity metrics.
• Establishes and maintains working relationships with providers, provider organizations and other stakeholders that supports contracting, provider relations, marketing and other organizational goals and objectives.
• Collaborates with leadership to ensure medical compliance with internal, regulatory and accreditation requirements.
• Provides medical expertise and direction for clinical policies, procedures, and programs.
• Serves on Quality Improvement & Health Equity Committee, Peer Review and Credentialing Committee, Grievance and Appeals Committee, Clinical Operations Committee and Physician Advisory Committees; serves on other committees as required.
• Represents HPSJ in a manner that promotes a positive image of HPSJ in the community.
• Assists with development of corporate and department budgets and metrics.

What You Bring:

Knowledge, Skills, Abilities and Competencies

Required

• In-depth knowledge of the principles and practices of managed care related to utilization management and/or case management and/or discharge planning.
• In-depth knowledge of the healthcare, economic or other issues affecting Medi-Cal and/or Medicare populations, providers and the underserved in San Joaquin and surrounding areas.
• Basic knowledge of managed healthcare as applied to government sponsored programs including Medicaid and SCHIP.
• Strong knowledge of and ability to identify, implement, monitor, and analyze relevant metrics models, and implement effective interventions based on results.
• In-depth knowledge of standard contract components and contract language specific to healthcare.
• In-depth knowledge of audit, control and monitoring processes, and the ability to effectively implement and maintain them.
• Financial acumen: Interprets and applies understanding of key financial indicators to make better business decisions.
• Strong skills in budget development and management.
• Manages complexity: Makes sense of complex, high quantity, and sometimes contradictory information to effectively solve problems.
• Decision quality: Makes good and timely decisions that keep the organization moving forward.
• Strategic mindset: Sees ahead to future possibilities and translates them into breakthrough strategies.
• Ability to execute and monitor relevant strategic and business plans.
• Resourcefulness: Secures and deploys resources effectively and efficiently; organizes people and resources to solve problems and identify opportunities.
• Plans and aligns: Plans and prioritizes work for self and others to meet commitments aligned with organization goals.
• Ensures accountability: Holds self and others accountable to meet commitments.
• Drives results: Consistently achieves results, even under tough circumstances.
• Strong collaboration skills with demonstrated ability to create and foster a collaborative work environment, maintain effective, high-performance teams, and organize people and resources to solve problems and identify business opportunities.
• Very strong interpersonal skills, with the ability to establish and maintain effective working relationships with individuals at all levels inside and outside of HPSJ.
• Very strong oral and written communication skills, with the ability to communicate professionally, effectively, and persuasively to diverse individuals and groups inside and outside of HPSJ.
• Strong presentation skills, including the ability to tailor presentations to a specific audience, and address and interact with large groups.
• Builds networks: Effectively builds formal and informal relationship networks inside and outside of the organization.
• Organizational savvy: Maneuvers comfortably through complex policy, process, and people-related organizational dynamics.
• Persuades: Uses compelling arguments to gain the support and commitment of others.
• Manages ambiguity: Operates effectively, even when things are not certain, or the way forward is not clear.
• Manages projects and deliverables on time and on budget.
• Promotes and maintains and ensures that direct reports promote and maintain an environment that supports HPSJ’s strategy, vision, mission, and values.
• Intermediate skills in Word and Excel.
• Ability to speak and be understood in English.
• Ability to handle confidential information with appropriate discretion.

Preferred

What You Have:

Education and Experience

Required

• MD degree from an accredited medical school.
• Satisfactory completion of an American Council of Graduate Medical Education accredited residency program.
• At least five years clinical experience in the practice of medicine in fields related to a managed care setting. A Master’s Degree in Public Health may be substituted for two years of the required clinical experience; and
• At least five years clinical experience in the practice of medicine with Medi-Cal and/or Medicare populations; and
• At least five years supervisory experience in a healthcare setting; or
• Equivalent combination of experience.

Preferred

Licenses, Certifications

Required

• Unrestricted license to practice medicine in the State of California, issued by the State Board of Medical Examiners, which meets the Health Plan’s credentialing and re-credentialing requirements.
• Board Certification in a chosen specialty.
• Valid California driver license and reliable transportation or, the ability to obtain transportation on demand in the counties served by HPSJ if prohibited from getting a driver license due to a medically documented disability.

What You Will Get:

HPSJ Perks:

• Competitive salary
• Robust and affordable health/dental/vision with choices in providers
• Generous paid time off (starting at 3 weeks of PTO, 4 paid floating holidays including employee’s birthday, and 9 paid holidays)
• CalPERS retirement pension program, automatic employer-paid retirements contributions, in addition to voluntary defined contribution plan
• Two flexible spending accounts (FSAs)
• Employer-Paid Term Life and AD&D Insurance
• Employer-Paid Disability Insurance
• Employer-Paid Life Assistance Program
• Health Advocacy
• Supplemental medical, legal, identity theft protection
• Access to exclusive discount mall
• Education and training reimbursement in addition to employer-paid elective learning courses.
• A chance to work for an organization that is mission-driven – our members and community are at the core of everything we do.
• A shorter commute ­– if you’re commuting from the Central Valley to the Bay Area.
• Visibility and variety – you have a chance to work with people at all levels of the organization, and work on diverse projects.

We are an equal opportunity employer and diversity is one of our core values. We believe that differences including race, ethnicity, gender, sexual orientation and other characteristics, will help us create a strong organization that is sensitive to the needs of those we serve. Employment decisions are made on the basis of qualifications and merit.

HPSJ provides equal employment opportunities to employees and applicants for employment and prohibits discrimination based on color, race, gender (including gender identity and gender expression), religion (including religious dress and grooming practices), marital status, registered domestic partner status, age, national origin (including language use) or ancestry, physical or mental disability, medical condition (including cancer and genetic characteristics), sex (including pregnancy, childbirth, breastfeeding or related medical condition), genetic information, sexual orientation, military or veteran status, political affiliation or any other characteristic made unlawful by applicable Federal, State or local laws. It also prohibits unlawful discrimination based on the perception that anyone has these characteristics, or is associated with anyone who has or is perceived to have these characteristics.

Important Notice: This job description is not a contract between HPSJ and the employee performing the job. The duties listed in the job description may be changed at the discretion of HPSJ, and HPSJ may request the employee to perform duties that are not listed on the job description.