Senior Medical Director
Company: Cambia Health Solutions, Inc
Location: Renton
Posted on: April 17, 2024
Job Description:
Senior Medical DirectorWashington - includes in state and out of
state travelSingle large employer focus Primary Job PurposeSenior
Medical Director provides clinical leadership and support to
clinical teams to ensure HCA members receive quality, cost
effective care yielding optimal outcomes, supports HCA's Health
Technology Assessment program, the Prescription Drug Program, the
Bree Collaborative, HEDIS and CAHPs performance and quality
program, and other the HCA-identified performance improvement
efforts as they relate to the UMP Plans and the State's health care
purchasing system. This will include HCA customized medical
policies and medical benefit design, WA state legislative mandates,
clinical escalation support, participation in development of and
organizational alignment to Bree Collaborative best practice
recommendations, participation in development of care
transformation strategic initiatives, and other requests from HCA.
General Functions and Outcomes
- Provides clinical leadership for staff to ensure members
receive safe, effective and cost efficient services.
- Contributes to the development of various medical management
strategies and tactics to drive results and achieve key performance
metrics.
- Conducts peer clinical review for medical necessity on
utilization management authorization requests.
- Provides clinical input on case management reviews working
closely with the CM clinical staff.
- Responsible for discussing review determinations with providers
who request peer-to-peer conversations.
- Participates on multiple teams to provide clinical input on
medical policy reviews and development and may participate on
committees that develop programs impacting clinical interventions,
utilization management and case management.
- Analyzes and uses data to guide the development and
implementation of health care interventions that improve value to
the member and employer.
- Advises Health Care Services Leaders on related key performance
metrics and the effectiveness of various efforts, initiatives,
policies and procedures.
- Identifies and communicates new opportunities in utilization
management, provider contracting or other areas that would enhance
outcomes and the reputation of the organization.
- Provides clinical expertise and coordinates between internal
clinical programs and providers of care to improve the quality and
cost of care delivered to health plan members.
- Ensures ethical decision making in compliance with contractual
arrangements, regulations and legislation.
- Supports internal communication or training that ensures
service is provided to members and providers by a well-trained
staff.
- Promotes provider understanding of utilization management and
quality improvement policies, procedures and standards.
- Provides guidance and oversight for clinical operational and
clinical decision-making aspects of the program.
- Has periodic consultation with practitioners in the field and
ensures that the organization has qualified clinicians accountable
for decisions affecting consumers.
- May manage staff including hiring, performance management,
development and retention.
- May participate in health plan credentialing operations and
clinical aspects of the credentialing program and provider services
support.Minimum Requirements
- Demonstrated competency working with hospitals, provider groups
or integrated delivery systems to effectively manage patient care
to improve outcomes.
- Strong communication and facilitation skills with internal
staff and external stakeholders, including the ability to resolve
issues and seek optimal outcomes.
- Proven ability to develop and maintain positive working
relationships with community and provider partners.
- Knowledge of the health insurance industry, state and federal
regulations, provider reimbursement methods and evolving
accountable care and payment models.
- General business acumen including understanding of market
dynamics, financial/budget management, data analysis and decision
making.
- Strong orientation to the application of data in managing
health and quality.
- Proven ability to develop creative strategies to accomplish
goals and objectives, plan and execute complex projects and
programs and drive results across internal teams and/or external
partners.
- Demonstrated ability to effectively lead and engage in a
constructive manner with others.Normally to be proficient in the
competencies listed aboveSenior Medical Director would have a MD or
DO degree, at least 5 years clinical experience, plus at least 2
years medical utilization management and/or case management
experience (prefer health insurance experience and additional MHA
or MBA training), or an equivalent combination of education and
experience.Required Licenses, Certifications, Registration,
Etc.Licensed Physician with an MD or DO degree. Active,
unrestricted license to practice medicine in one or more states or
territories of the United States. Board Certification required.
Qualification by training and experience to render clinical
opinions about medical conditions, procedures and treatments under
review.#LI-Remote
Keywords: Cambia Health Solutions, Inc, Kent , Senior Medical Director, Executive , Renton, Washington
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