Medical Director, Part-Time

Medical Director, Part-Time Ventura County Health Care Plan Oxnard, CA Job Details Part-time | Contract Up to $195,000 a year 3 hours ago Qualifications Overseeing medical necessity review Doctor of Medicine Utilization management peer review coordination Quality management HMO insurance plan management NCQA standards Medical credentialing Doctor of Osteopathy Health insurance management Senior leadership Full Job Description Job Summary We are seeking a dynamic and experienced Medical Director who will perform duties set forth in the California Knox-Keene Health Care Service Plan Act as well as regulations and Health and Safety code for VCHCP, a Department of Managed Health Care (DMHC) licensed Commercial HMO. This position is part of a team of 65 (including contractors), with no direct reports, and a $90 million dollar budget. In accordance with the National Committee on Quality Assurance (NCQA), the Medical Director, Ventura County Health Care Plan is responsible for the leadership and direction in planning, and coordinating medical reviewer staff to ensure appropriate, professional, and cost-conscious inpatient and outpatient health care to VCHCP assuring the quality of care provided to the members of the health plan by institutions, physicians, and allied professionals. As a licensed health plan, VCHCP is required to be compliant with all regulatory requirements of any other large insurance plan. Responsibilities Provides overall direction, guidance, and control for the medical components of VCHCP's services to ensure appropriate, professional, and cost-conscious health care. Develops and interprets medical policies. Coordinates and communicates matters of VCHCP medical policy with the Health Care Agency Director and Insurance Administrator, Utilization Management staff and Quality Assurance Staff. Participates, as a member of the Senior Management Team, in developing goals, plans and policies for the organization, assuring that the medical decisions will not be unduly influenced by fiscal and administrative management. Ensures that comprehensive medical benefits are effectively developed and administered for VCHCP patients. Conducts provider credentialing and Re-Credentialing. Develops practice profile indicators. Member of Credentialing, Quality Assurance {QA) and Peer Review Committees. Presents to Standing Committee identified provider quality concerns. Implements any Committee disciplinary actions, including any remedial and punitive measures. Reviews results of facility site surveys performed by Provider Services Administrator. Communicates with providers deficiencies identified in practice site surveys and monitors corrective action plans submitted by providers. Manages and controls inpatient utilization and outpatient referrals with attention to quality and cost-effective methods. Delegates performance of routine QA/UR activities to the QA/UR Nurses based upon guidelines approved by the medical director and Plan Committee. Provides or arranges timely review and response to requests for VCHCP services which require physician authorization {i.e., emergency hospital admissions, elective admissions, elective surgical procedures, referrals, tests, medication approvals requiring authorization.) Develops utilization management standards and guidelines for approval by the Utilization Management Committee consistent with sound clinical principles and processes and with current medical and scientific information. Communicates standards and guidelines to VCHCP providers. Member of Utilization Management, Quality Assurance, Pharmacy and Therapeutics and Standing Committees. Provides a timely review and response to Member complaints that involve denial of services or concerns related to medical quality. Develops and maintains professional and effective working relationships with Plan providers to optimize organizational growth and profitability. Responds to provider inquiries regarding Plan decisions, clarifies related matters as appropriate. Develops and implements Quality Assurance Plan. Develops Quality Assurance Indicators. Member of QA, Pharmacy & Therapeutics, and Standing Committees. Defines and monitors compliance with quality management standards and protocols in collaboration with Network Providers and the

VCHCP QA

Committee. Approves agenda and minutes for VCHCP QA and Utilization Management Committees. Ensures that Committee activities follow the guidelines set forth in the QA and UR plans and that Committee actions and assignments are completed in a timely manner as directed. Ensures that QA/Utilization Management Committee meetings are well attended by physicians of sufficient background and knowledge in the treatment of the medical conditions under discussion. Reviews all Potential Quality Issues {PQl's) identified by the Plan and initiates the request for information {including assessment by other QA entities) needed to assess the PQI. Rates each PQI for seriousness of the incident and reports the results to the QA Committee. Refers issues of provider quality concerns to the Plan's Credentials Committee and makes recommendations as to actions to be taken by the Plan. Implements disciplinary actions recommended by the Credentials Committee as defined by the Plan's Policy. Ensures that any actions taken by the Plan against a provider for medical quality issues will be reported to the appropriate oversight bodies. Participates in the recruitment, interviewing, selection, and performance appraisal of VCHCP providers. Represents the Plan in a liaison role with other agencies and individuals as apparent or assigned. Provides consultation to VCHCP management and staff as requested. Attends the meetings of the Standing Committee, the Plan's oversight committee. Presents the Plan's Utilization and Quality Reports and relays concerns identified by the Plan's Staff. Participates in Plan inter-rater reviews. Promotes Health Equity, Population Health Management, and quality standards. Performs related duties as assigned. Experience The ideal candidate will be collegial, engaged, and mission driven. The successful individual will have an extensive background in licensed HMO operations, regulatory requirements, chairing various required committee meetings and leading the medical services departments through changes in the healthcare delivery landscape.

Pay:

Up to $195,000.00 per year Application Question(s): Are you Board Certified in California?

License/Certification:

Doctor of Medicine or Osteopathy Degree? (Required)

Work Location:

In person