Medical Director

Benefits AlohaCare’s comprehensive benefits package includes low-cost medical, dental, drug and vision insurance, paid time‑off, 401k employer contribution, referral bonus, and pretax transportation and parking program. The Opportunity The Medical Director of CCS (Medical Director) is a key operational and strategic leader who assists the Director, Behavioral Health to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit. The Medical Director participates in activities such as prior authorization, appeals and grievances, committee work, Inter‑Disciplinary Team conferencing, community events, and coverage of medical colleagues. The Medical Director is mindful of the organization’s strategic goals, partnership with providers, engagement of members, closing gaps in care, and Medical Loss Ratio. The Medical Director complies with NCQA Accreditation standards, the QUEST Integration (Medicaid) Contract, and CMS rules and regulations. Primary Duties and Responsibilities Provides medical leadership of all utilization management, cost containment, and medical quality improvement activities. Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality decision making. Supports effective implementation of performance improvement initiatives for capitated providers. Assists Director, Behavioral Health in planning and establishing goals and policies to improve quality and cost effectiveness of care and service for members. Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements. Assists the Director, Behavioral Health in the functioning of the physician committees including committee structure, processes, and membership. Conduct regular rounds to assess and coordinate care for high‑risk patients, collaborating with care management teams to optimize outcomes. Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals. Participates in provider network development and new market expansion as appropriate. Assists in the development and implementation of physician education with respect to clinical issues and policies. Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components. Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care. Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality. Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment. Develops alliances with the provider community through the development and implementation of the medical management programs. As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues. Represents the business unit at appropriate state committees and other ad hoc committees. May be required to work weekends and holidays in support of business operations, as needed. Provides clinical oversight and guidance for AlohaCare on Substance Use Disorder issues, including issues such as the use of ASAM or other evidence‑based assessments and treatment protocols, the use of MAT and is active in teaching or training staff and, upon approval, students or professional trainees. Consults on AlohaCare clinical policy related to Substance Use Disorders and the cases of individual members for the CCS program on a routine basis. Attend community, State‑wide, or national conferences that have been prior approved and budgeted. Responsible for maintaining AlohaCare’s confidential information in accordance with AlohaCare policies, and state and federal laws, rules and regulations regarding confidentiality. Employees have access to AlohaCare data based on the data classification assigned to this job title. Requirements Doctor of Medicine or Osteopathy (MD/DO) Current unrestricted Medical License in State of Hawaii. Active Board Certification by the American Board of Medical Specialties. Minimum of 5 years of quality work in a health system, hospital, clinic, physician group, or health plan. Minimum of 5 years of clinical practice in direct patient care. Experience in medical leadership of clinical services, programs, or provider organizations. Able to effectively work in a fast‑paced and changing environment, manage multiple projects and priorities across multiple teams/projects and in a matrixed environment. Possesses excellent time management and organizational skills; is dependable, enthusiastic, self‑starting, and self‑motivated. Uses time effectively, reacts professionally under pressure. Practiced in a community health center or rural clinic. Previous experience as a Medical Director or Chief Medical Officer. Experience in a managed care organization or health plan. Advanced college degree such as Master of Public Health, Master of Healthcare Administration, or Master of Business Administration. Can continue to provide direct patient care up to half a day per week as approved. May require prolonged sitting – up to 4 hours. Requires prolonged operation of a computer workstation, including the ability to type for extended periods of time on a keyboard during the scheduled workday. Salary Range: $110.00 to $135.00 an hour #J-18808-Ljbffr