Senior Medical Director - Policy & Outcomes

Overview

What you can expect!

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an
authentic experience!

Reporting to the Vice President of Health Services, the Senior Medical Director Policy & Outcomes (Sr. Medical Director - P&O) is responsible for the strategic oversight of IEHP Medical Policies and clinical leadership around member health outcomes. The Sr. Medical Director - P&O oversees the day-to-day operations as it relates to developing, executing, leading and updating guidelines, policies, clinical pathways, and communications enabling effective health outcomes, as well as effective health plan performance as per DHCS, DMHC, CMS, and CCA clinical requirements. This leader serves as the accountable medical leader for clinical activities related to key activities including quality management, grievance and appeals, and appropriate clinical resource stewardship. The Sr. Medical Director - P&O also works in partnership with the appropriate cross functional departments to monitor the impact of policy outcomes through regular reporting, metrics, initiatives, and other improvement activities. This position is responsible for supporting regulatory audits for all its relevant domains

Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Additional Benefits

Perks

IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more.

Competitive salary

Hybrid schedule

State of the art fitness center on-site

Medical Insurance with Dental and Vision

• Life, short-term, and long-term disability options
• Career advancement opportunities and professional development
• Wellness programs that promote a healthy work-life balance

Flexible Spending Account – Health Care/Childcare

CalPERS retirement

457(b) option with a contribution match

Paid life insurance for employees

Pet care insurance

Key Responsibilities

Lead the development and execution of creating and/or updating medical policies and procedures to align with health plan regulatory requirements. Ensure guidelines and clinical pathways are updated with best practices, along with appropriate downstream connections to utilization management, population health, and other compliance and regulatory activities
Serve as clinical lead for efforts to promote appropriate evidence based clinical practices to improve member outcomes and support responsible stewardship of resources across all lines of business
Lead clinically, through strong partnerships with other departments for activities related to member outcomes, quality improvement, grievance and appeals, healthcare resource stewardship, and network corrective action plans. Develop and increase collaborative relationships with internal departments. Assure interdepartmental collaboration and communication with key business departments, including, but not limited to, compliance, member experience, provider relations, and claims
Serve as a liaison with providers, county public health partners and oversight agencies as assigned
Monitor network performance proactively to ensure adherence to policy standards. Develop and implement appropriate internal initiatives to address any issues impacting member outcomes
MAJOR RESPONSIBILITIES
Co-leadership with the Sr. Medical Director of Health Servies to advance IEHP’s Mission, Vision and Values. Work in partnership with the Senior Medical Director focusing on UM to coordinate daily huddles, develop work schedules, adherence to department metrics and KPIs, and training of medical staff
Manage medical directors, as well physician reviewers, working in the domains of policy, outcomes, grievances and appeals, quality management and clinical guideline development
Provide clinical direction to the Health Service team and act as a resource to all IEHP departments responsible for providing or coordinating clinical services to IEHP members
Direct, implement, and/or enhance medical policy, internal policies, and job aids as it relates to member safety and quality management activities, clinical guideline development, delegation and oversight, credentialing, peer review, and compliance related activities
Ensure medical decisions are rendered by qualified medical personnel, unhindered by fiscal or administrative management, with timely and appropriate use of UM criteria and guidelines
Direct clinical and workflow training for medical directors and physician reviewers within their oversight
Ensure medical personnel of the Plan and its delegates follow IEHP policies, protocols and rules of conduct consistent with the values of IEHP
Identify gaps in policies or activities relating to member outcomes and implement strategic, effective solutions
Serve as a primary point of contact for clinical, quality and performance issues for medical directors at delegated IPAs, as well as for providers in the IEHP direct network
Support other departments as needed to ensure timely completion of member grievances and appeals as required for regulatory compliance
Provide clinical leadership, support and/or guidance including, but not limited to, the following areas:
Inpatient claims reviews as needed
Utilization review
Member case management
Provider incentive programs
Credentialing, Peer Review and Member Safety Subcommittees
Audit preparation and participation
Projects involving total cost of care initiatives
Monitor, track, and trend data for appropriate utilization, and develop key initiatives to mitigate any unfavorable trends (e.g., over or under-utilization) using evidence based best practices
Reviews State mandated benefits to ensure IEHP is in full compliance through its policies
Perform any other duties as required to ensure Health Plan operations and department business needs are successful

Qualifications

Education & Requirements

• Seven (7) years of post-residency experience in a recognized medical specialty or practice, which must have included at least (3) years of medical administrative experience and a minimum of five (5) years of managed care or health plan leadership experience with proven track record of leading high performing physician teams
• Experience working with clinical practice guidelines and evidenced based criteria sets
• Has exposure to working with regulatory agencies
• Medical Director for an IPA, medical group, or CA HMO highly desirable. Medical specialty/practice experience preferably in the state of California
• Doctorate of Medicine from an accredited institution required
• Certification by one (1) of the American Specialty Boards required
• Completion of an accredited residency program required. Possession of an active, unrestricted, and unencumbered Physician’s and Surgeon’s Certificate issued by the State of California required
• (A physician certified in a state other than California may be employed prior to receipt of California certification provided that an application for a California physician and surgeon’s certificate is filed in the state of California prior to date of appointment.)

Key Qualifications

Expert level knowledge and thorough understanding of:

Managed Care principles

• Administrative practices and procedures (including but not limited to: credentialing and risk management, rules regulations, policies, and standards related to managed care)
• Principles of effective supervision and organization; methods, techniques, practices, principles, and literature in the broad field of medical sciences
• The principles of medical practice in a variety of settings (inpatient, outpatient, subacute, and similar items)
• Federal and state regulatory requirements, including CMS, DHCS, DMHC, CCA, NCQA, and associated clinical policy and compliance standards
• Cost-of-care levers, ut