Provide clinical oversight of all PriMed Hill Physician Utilization Management (UM) and
Requirements
5 years of post-residency experience in a recognized medical specialty, which must have included at least (3) years of managed care experience. Preferred experience is in adult primary care, such as family practice or internal medicine.
Experience working with clinical practice guidelines and evidenced based criteria sets.
Possesses strong knowledge of Managed Care principles, utilization and case management programs and has exposure to working with regulatory agencies.
Experience leading Quality Improvement efforts.
Knowledge of and experience with full and partial risk models in commercial, Medicare and Medi-Cal.
Knowledge of CMS and Medicaid regulations preferred, Medical Director for an IPA, medical group, or HMO highly desirable.
MD/DO degree from an accredited program, with an active, unrestricted California medical license.
Board certification.
A current CA license to practice without restriction.
3-5 years of supervisory/management/leadership experience in managed care setting.
Experience in delivery and implementation of Utilization Management and Care Management initiatives.
Benefits
Health insurance
Additional Information
We're delighted you're considering joining us!
At Hill Physicians Medical Group, we're shaping the healthcare of the future: actively managed care that prevents disease, supports those with chronic conditions and anticipates the needs of our members.
Join Our Team!
Hill Physicians has much to offer prospective employees. We're regularly recognized as one of the "Best Places to Work in the Bay Area" and have been recognized as one of the "Healthiest Places to Work in the Bay Area." When you join our team, you're making a great choice for your professional career and your personal satisfaction.
DE&I Statement:
At PriMed, your uniqueness is valued, celebrated, encouraged, supported, and embraced. Whatever your relationship with Hill Physicians, we welcome ALL that you are.
We value and respect your race, ethnicity, gender identity, sexual orientation, age, religion, disabilities, experiences, perspectives, and other attributes. Our celebration of diversity and foundation of inclusion allows us to leverage our differences and capitalize on our similarities to better serve our communities. We do it because it's right!
Job Description:
Under the direction of the Chief Medical Officer, the Senior Medical Director is responsible for clinical oversight and management of network performance. The Senior Medical Director works in partnership with the CMO and the VP of Clinical Services to ensure sound and compliant utilization management practices, ensure regulatory compliance, and support key clinical functions of the Utilization Management, Care Management and Appeals and Grievances teams. This key leader partners with the VP Clinical Services in the oversight of the inpatient and outpatient authorization review and denial process and is responsible for the training and mentoring of Physician Authorization Reviewers and Physician Advisors in the application and documentation of medical necessity criteria, the IRR process and response to audits. The Senior Medical Director of Network Performance collaborates with VP Population Health and may direct activities of the Regional Medical Directors to support organizational initiatives and to improve performance of individual practices. Support the advancement of the Clinically Integrated Network with recommendations on care guidelines, practice engagement and other priority areas. This leader is a key part of PriMed Hill Physicians' Senior Leadership Team and will be in office/onsite two days a week.
Key Areas of Focus:
Provide support and leadership in developing and implementing UM Strategy and Program.
Provide support and physician guidance on optimization of Care Management programs to improve outcomes for patients and value for plan partners.
Review and make recommendations on workflow, staffing, training, and quality improvement opportunities in our authorization review processes.
Partner with VP Population Health and team members to drive improvement on quality metrics through engagement of network practices.
Develop and increase collaborative relationships with external partners and stakeholders evidenced by improved clinical performance metrics.
Use of data analysis and reporting to track performance within full risk and partial risk agreements at the organizational and practice level and to identify improvement opportunities for network performance including member experience, access, appropriate care, site of service and potential cost savings.
Work collaboratively with operational and support teams to identify and implement improvement initiatives.
Support the work of the Utilization Management Committee, the Quality Improvement Committee, and others to include review of data, respond to committee inquiries, and ensure implementation of approved policies.
Primed · San Ramon, CA