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Medical Director, Santa Barbara, CA


CenCal Health

Medical Director

Santa Barbara, CA

July 30, 2019


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Medical Director

Director DIRME01157
Posted: April 26, 2019
Full-Time
Santa Barbara, CA, USA

Job Details

Description

  • Provides clinical leadership for medical management functions; assists subordinate managers in resolving medical claims review, grievances, appeals, and other medical management issues
  • Works closely with the CMO to identify medical service issues that have an impact on plan benefits and their administration, develop action plans and monitor results
  • Identifies, analyzes, and assists in identifying quality issues and trends; makes recommendations based on findings; develops and implements agreed upon changes
  • Provides clinical expertise needed to effectively and efficiently resolve complex, controversial and/or unique administrative circumstances. This includes working with internal and external groups
  • Conducts clinical reviews and makes UM decisions for prior, concurrent and retro authorizations, and appeals; approves/denies or offers medical alternatives according to CenCal Health medical review criteria, develops UM policies and procedures in coordination with Health Services staff
  • Works collaboratively with the Pharmacy team on clinical appropriateness of medication utilization
  • Establishes and maintains working relationships with providers, provider organizations and other stakeholders that support the health care system, quality improvement, integration of services, care coordination, contracting, provider relations, marketing and other organizational goals and objectives
  • Dedicated to process improvement and organizational efficiencies
  • Clinical oversight and development of care management strategies and opportunities
  • May support population health activities
  • No current direct reports, the position may supervise other Health Services staff in the future
  • May participate in committee assignments such as Credentialing, Peer Review, Pharmacy & Therapeutics, and/or Quality Improvement
  • Other duties as assigned

Qualifications

Behaviors

Required

  • Team Player: Works well as a member of a group
  • Functional Expert: Considered a thought leader on a subject
  • Thought Provoking: Capable of making others think deeply on a subject
  • Dedicated: Devoted to a task or purpose with loyalty or integrity

Motivations

Required

Ability to Make an Impact: Inspired to perform well by the ability to contribute to the success of a project or the organization

Education

Required

  • Medical Degree or better in Medicine.

Preferred

  • Masters or better in Public Administration or related field.

Experience

Required

  • Unrestricted medical license in California issued by the Board of Medical Examiners
  • 5 years: Clinical experience with managed care/utilization management

Preferred

  • Board eligibility in a chosen specialty; Board Certification preferred
  • Experience in UM/CM in a managed care setting
  • 3 years: Supervisory experience in a healthcare setting

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