DUTIES AND RESPONSIBILITIES:
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1 Position Title: MEDICAL DIRECTOR Position Status: Exempt Reports to: Chief Medical Officer Effective Date: 08/12/1999 Revised Date: 06/23/2006; 08/19/2009; 04/10/2012; 09/03/2013; 05/26/2015; 02/22/2016; 01/31/2018 SUMMARY DESCRIPTION: Under general direction, this position: 1. Provides clinical leadership within one or more of the Health Services functional areas including, but not limited to: Utilization Management, Quality Improvement, Pharmacy, and Care Management; 2. Develops and improves relationships with internal and external stakeholders, including the professional medical community and maintains and enhances communications with similar Health Plan organizations; 3. Participates in all aspects of regulatory compliance related to Health Services functions; and 4. Performs other duties as assigned. DUTIES AND RESPONSIBILITIES: 1. Provides clinical leadership within one or more of the Health Services functional areas including, but not limited to: Utilization Management, Quality Improvement, Pharmacy, and Care Management, with duties including but not limited to: Coordinating and consulting with department Directors regarding the clinical direction of programs, studies, activities, and processes; Participating in the development, interpretation, and presentation of reports and analytics needed for improvement; Participating in the general administration of the Alliance, as a member of the executive management team by providing input into the problem-solving and decision making process; In conjunction with department Directors and leadership, developing annual work plans, program descriptions, year-end reports, annual evaluations, and reviewing and updating policies; Participating in strategic planning and implementation of Medical Affairs Administration operational goals related to the growth and development of Alliance business operations; Modeling and promoting effective interdepartmental communication; Drafting, recommending and implementing administrative policies, processes and procedures related to Medical Affairs Administration operations; Page 1 of 5
2 Providing input on clinical content for specific programs; Taking a leadership role in strategic planning, Clinical Effectiveness and Quality Initiatives and other operational programs; Providing clinical leadership regarding provider relations and member relations; and Providing support to the Chief Medical Officer Utilization Management Responsibilities: Providing clinical leadership for medical decisions regarding hospital Concurrent Review on Alliance inpatient members; Reviewing Authorization Requests as referred by Utilization Management staff for approval or denial of requested services; Evaluating member requests for administrative membership categories; Evaluating physician requests for member reassignment; Participating in staged resolution of authorization appeals and communicating with providers and members regarding utilization management issues and questions; and Directing and interpreting data based on utilization analysis, including overutilization, underutilization, and cost trending in key areas (inpatient, pharmacy, Emergency Department (ED) use, etc.). Quality Improvement Responsibilities: Assessing requirements and needs for mandatory, and optional, health promotion programs; Recommending study design, oversight, and feedback mechanisms for quality improvement projects; Participating, as assigned, in internal quality review activities; Evaluating potential quality of care incidents, communicating with providers regarding such incidents, and developing Corrective Action Plans as needed; Participating in the Alliance complaint and grievance resolution process including State Fair Hearings as needed; Participating in peer review activities; and Identifying fraud, waste, and abuse and working with the Alliance Compliance Program to address those issues. Pharmacy Management Responsibilities: Participating in the development, implementation, and monitoring of the Alliance drug formulary; Providing clinical support and leadership to the Pharmacy Department drug utilization management process including practitioner interface as appropriate, and overseeing appropriate denials; and Assisting in the Pharmacy Benefit Manager (PBM) and pharmacy consulting services relationships including the PBM Request for Proposal (RFP) process. Page 2 of 5
3 Care Management Responsibilities: Collaborating and consulting with the Care Management Director to set the clinical direction and implement disease management, care coordination and complex case management programs as needed; Collaborating with the Care Management Director to ensure that Care Management programs support Alliance strategic initiatives including utilization and quality targets; and Supporting coordination of internal, provider and other external care management resources. 2. Develops and improves relationships with internal and external stakeholders, including the professional medical community and maintains and enhances communications with similar Health Plan organizations, with duties including but not limited to: Attending and/or chairing local medical meetings and committees, such as Hospital Joint Operating Committee, Physicians Advisory Group (PAG), Peer Review and Credentialing Committee (PRCC); Participating in the Alliance s internal committees and workgroups, such as: Clinical Quality Improvement Committee (CQIC),,Quality Improvement Work Group (CQIW), Utilization Management Committee (UMC), Utilization Management Work Group (UMWG), Reassignment Committee, Appeals and Grievances Committee, Compliance Committee, etc.; Participating in community forums related to the Alliance s goals and mission; Participating in information sharing, discussions, and problem solving meetings with other Health Care organizations and community agencies; Evaluating disputes regarding Primary Care Physician performance; Informing and educating the professional community about the Alliance and its programs; Participating in academic detailing outreach to providers regarding Care Based Incentives, Quality Improvement Programs, Utilization Management best practice and Care Management Programs; and Serving as a liaison for network physicians who have questions, suggestions, feedback and/or complaints. 3. Participates in all aspects of regulatory compliance related to Health Services functions, with duties including but not limited to: Reviewing requirements for State and Federal audits; Preparing and reviewing materials related to compliance requirements; Participating as needed in regulatory discussions, meetings, and conferences; and Participating in Statewide Medi-Cal Managed Care Medical Director communications and related meetings as assigned. 4. Performs other duties as assigned. Page 3 of 5
4 EDUCATION AND EXPERIENCE: Current unrestricted California license to practice Medicine. Doctor of Medicine degree from an accredited medical school and experience working in medical programs administration, peer review process administration, and serving in a leadership capacity or an equivalent combination of education and experience which would provide the required knowledge, skills and abilities may be qualifying. JOB SPECIFIC KNOWLEDGE, SKILLS AND ABILITIES: Thorough knowledge of current principles and practices of medicine; Working knowledge of data collection and management practices, as related to utilization and quality of medical care; Working knowledge of computer data systems; Working knowledge of the principles and practices of program development and project management; Working knowledge of health care regulatory processes; Working knowledge of and proficiency with Windows based PC systems and Microsoft Word, Outlook, PowerPoint and Excel; Some knowledge of managed care, Medi-Cal, and Medicare programs; Ability to build trust and rapport with the local provider community and other health plans; Ability to quickly learn the unique demographics and medical needs of the three counties served by the Alliance; Ability to develop, plan, organize and direct programs and activities that are complex in nature and regional in scope; Ability to provide leadership, facilitate meetings, and partner with and guide managers and employees in the resolution of issues; Ability to clearly explain and follow Alliance processes and policies; Ability to act as a resource to clinical and non-clinical staff; Ability to understand and interpret complex clinical reports, data and analytics; Ability to identify issues and resolve complex problems with creativity and resourcefulness; Ability to demonstrate sensitivity, empathy and understanding to a culturally diverse member population; Ability to manage multiple projects simultaneously, organize work, and achieve goals and timelines; Ability to prepare oral and written reports, correspondence and other program documents; Ability to make presentations and adjust communication style in order to facilitate collaboration and understanding; ; and Willingness to perform work at satellite Alliance offices in order to fulfill geographic specific responsibilities, as directed by the Chief Medical Officer. ALLIANCE STANDARD KNOWLEDGE, SKILLS AND ABILITIES: Ability to communicate effectively, both orally and in writing; Ability to establish and maintain effective and cooperative working relationships with Alliance staff and others contacted in the course of the work; Page 4 of 5
5 Ability to assume responsibility and exercise good judgment in making decisions within the scope of authority of the position; Ability to think and work effectively under pressure and accurately complete tasks within established times; Ability to prioritize tasks and meet deadlines; Ability to maintain confidentiality; and Valid California Driver s License, transportation, and automobile liability insurance in limits acceptable to the Alliance. DESIRABLE QUALIFICATIONS: Significant practice experience. Experience with managed care, Medi-Cal, and Medicare programs. Experience working with systematic quality assurance and improvement and public health and epidemiology programs. Working knowledge of complex/chronic clinical conditions. Working knowledge of the medical communities in Santa Cruz, Monterey and Merced counties. Board Certification. Bilingual (English/Spanish or English/Hmong). WORK ENVIRONMENT AND PHYSICAL DEMANDS: Ability to sit in front of and operate a video display terminal for extended periods of time; Ability to bend, lift and carry objects of varying size weighing up to 10 pounds; and Ability to travel to different locations in the course of work. ALL ALLIANCE EMPLOYEES ARE EXPECTED TO: Comply with all Alliance safety requirements; and Adhere to all Alliance policies and procedures. The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform. The Alliance reserves the right to revise this job description at any time. Page 5 of 5
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