Medical Director, Quality Improvement / Job Req 772019971 at ALAMEDA ALLIANCE FOR HEALTH in Alameda, California

Job Description:

PRINCIPAL RESPONSIBILITIES:
The Medical Director is a member of the Medical Management Department of the Alameda Alliance for Health (health plan) and assists the Chief Medical Officer in developing and implementing clinical policy designed to meet the DHCS triple aim: improving the patient experience of care; improving the health of populations; and reducing the per capita cost of health care. The Medical Director serves as the clinical lead of a particular area(s) of the HCS Department and works collaboratively with the areas operational lead(s). The Medical Director serves as the liaison to the provider network as well as key county, agency and other community programs on behalf of the Alliance.
Principal responsibilities include:
Quality Management and Clinical Services Oversight:
With the Chief Medical Officer, and Sr Director of Quality, lead efforts to meet joint Quality and regulatory requirements and accreditation standards. Share accountability for Medical Services NCQA requirements and improving HEDIS and CAHPS performance year over year with Sr Director of Quality Assist in the development of an overall strategic direction for quality improvement and accreditation. Develop, implement, monitor and determine outcomes of quality improvement projects and programs to achieve outstanding utilization results. Oversee Potential Quality Issue (PQI) and Facility Site Review (FSR) programs. Assist to develop, implement and monitor the Disease Management Program Review PQI cases. Work with Analytics to assess and refine the Pay for Performance program. Monitor physician compliance with contractual responsibilities in conjunction with the Provider Services department, particularly in the areas of quality improvement, including access and availability, initial health assessment and quality improvement projects and evaluations. Ensure that medical care meets standards for acceptable medical care and establish comprehensive, understandable standards of clinical care that identify desirable, observable characteristics of care, based on state-of-the art, community, state and national practice guidelines. Ensure that medical decisions are rendered by qualified medical personnel, unhindered by fiscal or administrative management. Participate in completing assigned Prior Authorization medical necessity reviews, resolving medically related and potential quality related issues, and issue authorizations, modifications and denials. Participate in the development of utilization management (UM) criteria and clinical protocols and participate in the analysis of trends to recommend policy, program and practice changes to achieve outstanding utilization results. Participate in the Quality Improvement Health Equity Committee, Pharmacy and Therapeutics Committee, Utilization Committee, Peer Review & Credentialing Committees including JOMs, and other committees, as assigned by the CMO. Monitor physician compliance with contractual responsibilities in conjunction with the Provider Services department, particularly in the areas of quality improvement and accreditation. Outreach to and encourage providers to close gaps in care and work collaboratively with Alameda Alliance for Health to improve quality of care and meet accreditation requirements. Assist in the clinical oversight of the health education programs and services and ensure that the needs of members for health education services are met. Provide oversight of member communication of health education materials Participate in various sub-committees not limited to A&A, C&L, and UM Committees. Complete other tasks/projects as assigned by the Chief Medical Officer.
Additional Duties:
Serve as intermediary between the Alliance and providers, maintain effective and consistent communications and professional relationships with providers and represent the concerns and recommendations of physicians. Assist in recruitment and orientation of participating health plan providers. Consult in the development and implementation of new products and benefits. Assist in promoting the use of web technology by physicians and consumers in conjunction with the health plans strategies.
ESSENTIAL FUNCTIONS OF THE JOB
Participate in hiring, supervising, and training of staff. Hybrid position requiring in-person visits to providers, clinical sites, and community partners. Work with the analytics team to review and refine reports on high risk, high cost members and other reports as needed. Work with the Chief Medical Officer, other AAH Medical Directors, and providers in the community to develop and advocate for programs and delivery systems that provide high-quality, cost-effective services (e.g. academic detailing, physician/clinic provider meetings). Perform continuing evaluation and modification of the health plans programs regarding the quality and efficiency of health care delivery. Assist in the development of first-rate, collaborative clinical management teams and supports inter-plan communication, cooperation and collaboration. At the direction of the Chief Medical Officer to provide support and appropriate direction to staff on UM issues. (e.g. prior authorizations, PQI, clinical case reviews and dispositions, clinical grievances etc.). Assist in developing and revising policies to support UM activities, including criteria and guidelines for appropriate use of services, clinical practice guidelines and treatment guidelines. Comply with the organizations Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.
PHYSICAL REQUIREMENTS
Constant and close visual work at desk or computer. Constant sitting and working at desk. Frequent data entry using a keyboard and/or mouse. Frequent use of telephone headset. Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person. Frequent lifting of folders and various objects weighing between 0 and 30 lbs. Frequent walking and standing.

Number of Employees Supervised: 0
MINIMUM QUALIFICATIONS:
EDUCATION OR TRAINING EQUIVALENT TO:
Current Doctor of Medicine, active, unrestricted licensed in the State of California, Board certified. MPH and/or MBA strongly desired.
MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:
Two years experience in a managed care environment, physician group management or integrated health care system management. Five years experience in the practice of medicine. Minimum three years supervisory experience. Previous experience in a Duals Special Needs Plan preferred

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):
Experience and current knowledge in clinical program administration, including utilization management and/or quality management. Proven track record with tangible results in clinical quality improvement and cost management. Ability to think strategically and bring vision to the position. Ability to integrate clinical and financial data for improved management of clinical programs. Ability to develop and maintain successful working relationships with external constituents, physicians, hospitals, ancillary providers, regulators, government officials and the media. Knowledge of California public health care programs. Experience serving culturally diverse populations. Successful track record as a team player, collaborative style and exceptional interpersonal skills. Excellent oral and written communication skills. Experience in use of various computer system software as well as Windows and current Microsoft Office suite.
SALARY RANGE $252,198.43-$378,297.65
The Alliance is an equal opportunity employer and makes employment decisions on the basis of qualifications and merit. We strive to have the best qualified person in every job. Our policy prohibits unlawful discrimination based on race, color, creed, gender, religion, veteran status, marital status, registered domestic partner status, age, national origin or ancestry, physical or mental disability, medical condition, genetic characteristic, sexual orientation, gender identity or expression, or any other consideration made unlawful by federal, state, or local laws. M/F/Vets/Disabled.