Associate Medical Director

Associate Medical Director at AllCare Health with the Medical Director department in Grants Pass, Oregon

We Are Seeking Qualified Candidates to Join Our Team!

AllCare Health offers competitive wages, an excellent benefits package including affordable healthcare, 401k retirement, wellness programs, and flexible schedule options.

Summary

This position is responsible for overseeing the day-to-day medical management activities of the department, including but not limited to utilization reviews, appeals and grievances, case consultations, and recommendations, by performing the following duties.

Essential Duties

1. Assists with the development and maintenance of all medical and departmental policies and procedures to support the utilization management process.

2. Works with the Chief Medical Officer to establish, implement, and monitor a departmental plan to address resource and cost utilization to ensure optimal health plan member experience and corporate performance and fiscal goals are met.

3. Collaborates with the Chief Medical Officer and Director of Quality/Government Relations to ensure departmental compliance with all required regulatory and accreditation agencies.

4. Makes clinical service determinations based on medical appropriateness, utilizing applicable criteria and guidelines and can deny requests based on medical necessity and/or not meeting criteria, policy, or appropriateness.

Job Duties

• Leads and/or participates in corporate and community committees, task forces, and project initiatives as business needs require.
• Serves as a subject matter expert in Medical Management interpreting regulatory requirements and coordinating processes to support requirements.
• Works with senior management to identify and develop health plan departmental objectives and strategies to maximize operations that support corporate strategies and initiatives.
• Coordinates the development and annual review of medical policies, procedures, and standards for the department to ensure they meet CMS, Oregon Health Plan, and NCQA requirements.
• Collaborates with Chief Medical Officer and Chief Quality and Compliance Officer to ensure departmental compliance with all required regulatory and accreditation agencies.
• Serves as a professional role model while supporting the organization’s mission, vision, and values in all departmental activities.
• Works with all types of members, regardless of age, ethnicity, medical or mental impairment, disability, or dissatisfaction with the Health Plan.
• Participates in organizational committees, including Credentialing, Patient Care, Quality Improvement and Pharmacy Committee as needed.
• Participates in departmental staff meetings, utilization management conferences, and case review sessions.
• Supports Medical Management staff activities that ensure members are receiving quality and efficient member care coordination.
• Ensures an optimal member experience maximizing customer satisfaction.
• Serves as lead Medical Management liaison to AllCare Independent Physicians and other providers by collaborating with other health plan constituents and communicating departmental processes.
• Supports Chief Medical Officer in IPA physician recruitment and credentialing efforts.
• Refers situations to the Quality Committee, Corporate Compliance, Fraud & Abuse, or Legal Services when appropriate.
• Ensures Medical Management departmental compliance with all confidentiality and HIPAA requirements.
• Maintains punctual, regular, and predictable attendance.
• Works collaboratively in a team environment with a spirit of cooperation.
• Respectfully takes direction from leadership.
• Meets all required training including those listed in Relias Learning Module System (LMS).
• Performs other duties as assigned.

On Call Responsibilities

This position has light on-call responsibilities on weekends for emergent prior authorization requests as part of the UM on-call team. These responsibilities rotate among the other medical directors and the Chief Medical Officer.

Supervisory Responsibilities

This position does not have any supervisory responsibilities.

Job Requirements

• May require the use of personal vehicle for local travel (subject to mileage reimbursement).
• May require the use of a personal cell phone (cell phone stipend applicable).

Qualifications

Ability to perform essential job duties with or without reasonable accommodation and without posing a direct threat to safety or health of employee or others. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.

All health care providers who are HIPAA covered entities, whether individuals or organizations, must get an NPI. Under HIPAA, you’re a covered health care provider if you electronically transmit health information in connection with a HIPAA standard transaction, even if you use a business associate to do so.

AllCare Health employs staff that are defined under OHA or CMS as health care providers. Positions that are defined as providers include, but are not limited to, Doctors, Nurse Practitioners, Physical Therapists, Traditional Health Workers, and Certified or Qualified Healthcare Interpreters.

Education

Doctoral degree (M.D. or D.O.) or advanced practice license, such as Nurse Practitioner or Physician Assistant.

Experience

• Five years of clinical experience.
• Two years of previous experience in Utilization, Case and/or Disease Management or Wellness preferred.
• Knowledge of CMS Guidelines, CPT Codes, InterQual, HIPAA, ICD-10 Codes, Milliman Care Guidelines, and NCQA preferred.
• Ability to handle multiple tasks, often within time constraints.
• Ability to handle stressful and dynamic work situations.
• Ability to work extended hours to see issues through to resolution.
• Ability to effectively communicate with all members of the health care team, members, families and fellow staff members.

Certificates, Licenses, and/or Registrations

• Current Oregon Medical License free of any restrictions or disciplinary action pending and able to legally and independently practice without the supervision of another licensed professional or eligible to apply for an Oregon MD/DO/NP/PA license.
• Current board certification in the designated clinical field, as applicable.
• Valid Oregon driver’s license & proof of current vehicle insurance.

Technical Skills

• Familiarity with the healthcare industry.
• Excellent organization and time-management skills.
• Excellent computer skills, including the Microsoft Office Suite (Outlook, Word, PowerPoint, and Excel).
• Knowledge of and compliance with HIPAA regulations.
• Knowledge of project management and/or change management.
• Excellent at identifying and implementing improvement activities and ensuring excellence.
• Knowledge of research methodologies and/or data analysis.
• Excellent at interpreting data and using it to solve problems and gain new insights.
• Excellent at locating information and synthesizing information from various sources.
• Knowledge of customer service and service recovery best practices.
• Knowledge of CMS Guidelines, CPT Codes, InterQual, HIPAA, ICD-10 Codes, Milliman Care Guidelines, and NCQA preferred.

Language Skills

Ability to read, analyze, and interpret the most complex documents. Ability to respond effectively to the most sensitive inquiries or complaints. Ability to write speeches and articles using original or innovative techniques or style. Ability to make effective and persuasive speeches and presentations on controversial or complex topics to top management, public groups, and/or boards of directors.

Mathematical Skills

Ability to apply advanced mathematical concepts such as exponents, logarithms, quadratic equations, and permutations. Ability to apply mathematical operations to such tasks as frequency distribution, determination of test reliability and validity, analysis of variance, correlation techniques, sampling theory, and factor analysis.

Computer Skills

Has advanced specialized computer skills that require mastery of applicable software in such fields as graphic design, video production, technical writing, statistics and web based training.

Reasoning Ability

Ability to apply principles of logical or scientific thinking to a wide range of intellectual and practical problems. Ability to work with nonverbal symbolism (formulas, scientific equations, graphs, musical notes, etc.,) in its most difficult phases. Ability to work with a variety of abstract and concrete variables.

Interpersonal Skills

• Trust: Promotes honesty, transparency, and diligence. Approaches leadership with mindset of “power with” rather than “power over” and regularly includes others in planning and decision-making. Able to make and communicate difficult decisions in the best interest of AllCare Health.
• Innovation: Ready to take advantage of unexpected opportunities; adapts quickly to change and is a teacher to assist with change within the organization. Commits to solving unresolved issues in an effort to collaborate and model problem solving. Proactively develop solutions to challenges, including by constantly looking at big-picture progress and thinking about people.
• Relationships: Enthusiasm for meeting and engaging with people. Able to put people at ease, especially when there are lines of difference. Identifies and intervenes in problematic dynamics. Listens closely to understand needs or concerns and takes steps based on that input. Gets back to people in a timely manner. Takes pride in providing clear, helpful information.
• Voice: Brings a clear vision and recognizes the value of divergent perspectives. Provides equity-centered conflict transformation