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Medical Director, Alameda, CA


Alameda Alliance for Health

Medical Director

Alameda, CA

May 25, 2017


The Medical Director is a member of the Medical Management Department of the Alameda Alliance for Health (“health plan”), and assists the Chief Medical Officer in developing and implementing clinical policy designed to meet the DHCS triple aim: improving the patient experience of care; improving the health of populations; and reducing the per capita cost of health care. Medical Directors lead one of two distinct areas: Quality Management or Clinical Services (utilization and case/disease management). The Medical Director serves as the liaison to the provider network as well as key county, agency and other community programs on behalf of the Alliance.

Clinical Services Oversight:

  • Ensure that medical decisions are rendered by qualified medical personnel, unhindered by fiscal or administrative management.
  • Lead efforts to meet UM, Case & Disease Management regulatory requirements and accreditation standards.
  • Ensure that medical care meets standards for acceptable medical care and establish comprehensive, understandable standards of clinical care that identify desirable, observable characteristics of care, based on state-of-the art, community, state and national practice guidelines.
  • Lead assigned Prior Authorization medical necessity review process, resolving medically related and potential quality related issues, and issue authorizations, modifications and denials.
  • Develop utilization management (UM) criteria and clinical protocols and analyze trends to recommend policy, program and practice changes to achieve outstanding utilization results.
  • Assist in the development of an overall strategic direction of utilization management and case/ disease management.
  • Participate in the Health Care Quality Committee, Pharmacy and Therapeutics Committee, and Peer Review & Credentialing Committees as well as work with ad-hoc physician and provider committees.
  • Monitor physician compliance with contractual responsibilities in conjunction with the Provider Services department, particularly in the areas of utilization review and case/disease management.
  • Encourage providers to manage effectively the delivery of health care and Alliance members to use the delivery network effectively and appropriately.
  • Assist in the clinical oversight of the health education programs and services, and ensure that the needs of members for health education services are met.
  • Provide oversight of member communication that has clinical information.
  • Perform other duties as requested.

Quality Management Oversight:

  • Lead efforts to meet Quality Improvement regulatory requirements and accreditation standards.
  • Lead efforts to achieve outstanding HEDIS and CAHPS results.
  • Lead PQI and FSR programs.
  • Ensure that medical decisions are rendered by qualified medical personnel, unhindered by fiscal or administrative management.
  • Lead assigned Prior Authorization medical necessity review process, resolving medically related and potential quality related issues, and issue authorizations, modifications and denials.
  • Assist in the development of an overall strategic direction of continuous quality improvement and accreditation programs.
  • Participate in the Health Care Quality Committee, Pharmacy and Therapeutics Committee, and Peer Review & Credentialing Committees as well as work with ad-hoc physician and provider committees.
  • Monitor physician compliance with contractual responsibilities in conjunction with the Provider Services department, particularly in the areas of quality improvement, including access and availability, initial health assessment and quality improvement projects and evaluations.
  • Develop, implement, monitor and determine outcomes of quality improvement projects and programs to achieve outstanding utilization results.
  • Perform other duties as requested.

Additional Duties:

  • Serve as intermediary between the Alliance and providers, maintain effective and consistent communications and professional relationships with providers and represent the concerns and recommendations of physicians.
  • Assist in recruitment and orientation of participating health plan providers.
  • Consult in the development and implementation of new products and benefits.
  • Assist in promoting the use of web technology by physicians and consumers in conjunction with the health plan’s strategies.
  • Complete other tasks/projects as assigned by the Chief Medical Officer.

To apply visit https://jobs-alamedaalliance.icims.com/jobs/1661/medical-director/job


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