Senior Medical Director - Policy & Outcomes

Senior Medical Director Policy & Outcomes

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 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

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
• 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

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, utilization patterns, total cost of care initiatives, and financial drivers within value?based environments
• Managing complex grievance and appeals issues, ensuring compliance, timeliness, and defensible clinical rationale
• Familiarity with local healthcare organizations and/or local practice experience preferred
• Advanced proficiency in:
• Communication skills (written and verbal), both clinical and operational, for cross-functional collaboration across departments
• Policy development skills
• Analytical and data interpretation skills; problem solving
• Presentation skills
• Microcomputer applications such as Microsoft Word, Excel, and Access
• Demonstrated ability to:
• Maintain clinical independence, ensuring medical decision-making is free of inappropriate administrative or financial influence
• Be an assertive communicator
• Be an effective leadership of other physicians and clinical staff
• Have a track record of leading with accountability
• Possess a strong attention to