Job Description:
Looking for a way to make an impact and help people?
Join PacificSource and help our members access quality, affordable care!
PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.
Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.
Under the leadership of the Senior Medical Director, the Medical Director is responsible for the management of the PacificSource Commercial, Medicare, and Medicaid Lines of Business. This position will work closely with the Vice Presidents of each Line of Business in addition to other internal and external stakeholders to both develop and support initiatives in support of our membership and provider partners.
Essential Responsibilities:
- Review and make clinical determinations on coverage for pre- or post-service requests in accordance with evidence-based guidelines, CMS coverage guidelines to include the Medicare Benefit Policy Manual, National Coverage Determinations (NCD), and Local Coverage Determinations (LCD) in addition to internal PacificSource policies. The determinations include but may not be limited to physical health, behavioral health, and oral health.
- Collaborate with stakeholders across the organization to create and drive clinical and business strategies focused on improving clinical performance, member experience, trend management, and quality.
- Participate actively in various external and internal committee meetings as assigned.
- As requested, develop strategy and subsequently engage with regulatory entities to fulfill obligations and execute on contractual commitments associated with the line of business.
- Lead clinical activities connected to PacificSource's growth for each line of business and participate as a key leader.
- Participate in other clinical or administrative oversight, planning or management as designated from time to time.
- Work with the Senior Medical Director and the Chief Medical Officer on various projects as assigned.
- Coordinate business activities by maintaining collaborative partnerships with key departments.
- Actively participate in the organization as a team member and physician leader at all times.
- Understand and apply knowledge of risk adjustment and hierarchical condition categories as it relates to clinical documentation and willingness to engage in continuous improvement strategies.
Supporting Responsibilities:
- Meet department and company performance and attendance expectations.
- Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
- Perform other duties as assigned.
SUCCESS PROFILE
Work Experience: At least five (5) years of clinical experience required. Leadership experience in health insurance, provider organization, or closely related experience strongly preferred. Significant senior management policy and decision-making experience, including developing and implementing management best practices preferred.
Education, Certificates, Licenses: Doctor of Medicine (MD or DO) with an unrestricted license to practice medicine in in any of the four states (MT, ID, WA, OR), or be willing to apply for state licensure in one of these four states. Board certification recognized by American Board of Medical Specialties (ABMS) is preferred.
Knowledge: Comprehensive knowledge of business principles and techniques of administration, organization, and management to include an in-depth understanding of the key business issues that exist in the healthcare industry. These include, but are not limited to, quality improvement including, Lean methodology, healthcare economics, personnel administration, financial and cost analysis, and trends in the healthcare industry. Excellent understanding of all areas of medical conditions, treatment, and care. Excellent understanding of the insurance industry and risk factors and how they relate to the PacificSource organization. Demonstrated skills with the following software: Microsoft word, PowerPoint, and Excel.
Competencies:
Authenticity
Building Organizational Talent
Cultivating Networks
Customer Focus
Empowerment/Delegation
Emotional Intelligence
Establishing Strategic Direction
Optimizing Diversity
Passion for Results
Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 10% of the time.
Skills:
Accountable leadership, Business & financial acumen, Empowerment, Influential Communications, Situational Leadership, Strategic Planning
Our Values
We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:
- We are committed to doing the right thing.
- We are one team working toward a common goal.
- We are each responsible for customer service.
- We practice open communication at all levels of the company to foster individual, team and company growth.
- We actively participate in efforts to improve our many communities-internally and externally.
- We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.
- We encourage creativity, innovation, and the pursuit of excellence.
Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.
Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.
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