Senior Medical Director
Department: Health Services Administration
Location: San Francisco, CA
Do you have the desire and passion to improve the delivery of healthcare?
As the Senior Medical Director at San Francisco Health Plan (SFHP) you will be responsible for clinical oversight and management of all SFHP Utilization Management (UM) and Case Management (CM) functions. This role works in partnership with Vice President of Health Services Operations and Vice President of Health Services Programs to shape the strategic direction, implement new initiatives, ensure regulatory compliance and execute key clinical functions of these departments. This position serves as a teacher and mentor to Medical Directors and clinical staff to foster professional growth and development.
Critical areas of focus for this role include:
- Develop and implement clinical programs to align with SFHP’s strategic priorities in order to improve quality of care and outcomes for members.
- Provide leadership in developing and implementing UM Strategy and Programs.
- Lead the clinical team and provide clinical oversight, direction and mentoring.
- Develop and increase collaborative relationships with external partners and stakeholders evidenced by improved clinical performance metrics.
- Monitor network performance proactively to ensure adherence to health plan standards, and execute initiatives to address issues affecting performance.
- Assure interdepartmental collaboration and communication with provider contracts, provider relations and claims and others resulting in a quality network of providers.
WHAT YOU WILL DO
- Identify areas of risk and opportunities to optimize utilization management.
- Participate in a formal Utilization Management Program for the Plan and its Providers.
- Develop and execute solutions to monitor Utilization Management.
- Consult and advise on the development of protocol, procedures, oversight and training in the following areas:
- Pre-admission authorization
- Prospective, concurrent (inpatient) and retrospective review
- Long Term Care Services and Support including Skilled Nursing and Subacute care
- Inpatient claims review
- Utilization/Medical Management review reporting and evaluation
- SFHP led Member Case Management
- Potential Clinical Quality Issues
- Grievance resolution
- Actively participate and provide physician leadership in several SFHP Committees.
- Provide physician leadership and clinical support for NCQA activities of the Plan.
- Provide physician leadership for UM and CM Delegation oversight activities of the Plan, including Behavioral Health.
- Understand and advise the day to day clinical operations of the Plan, and links respective business operations / business strategy with outcomes.
- Model data-driven leadership, ensuring interventions are measured and evaluated for efficacy and impact.
- Strategic thinking & functioning
- Dealing with ambiguity & creativity
- Engages others and builds a healthy environment
- Organization & leadership development
- Community leadership
WHAT YOU WILL BRING
- 5 years of post residency experience in a recognized medical specialty, which must have included at least (3) years of medical administrative experience.
- Preferred experience is in adult primary care, such as family practice or internal medicine.
- MD, DO Degree
- Board certification
- 3-5 years of management and leadership experience in managed care setting
- Experience working with clinical practice guidelines and evidenced based criteria sets.
- Strong knowledge of Managed Care principles, Utilization and Case management programs and exposure to working with regulatory agencies.
- Knowledge of CMS and Medicaid regulations.
- Medical Director for an IPA, medical group or HMO highly desirable.
- Experience in delivery and implementation of Utilization Management and Quality initiatives.
- Knowledge of Health Plan/ Integrated Delivery system models of case management and care coordination best practices.
Established in 1997, San Francisco Health Plan (SFHP) is a an award winning, managed care health plan whose mission is to provide affordable health care coverage to the underserved low and moderate-income residents in San Francisco county. SFHP is chosen by eight out of every ten San Francisco Medi-Cal managed care enrollees and its 135,000+ members have access to a full spectrum of medical services including preventive care, specialty care, hospitalization, prescription drugs, and family planning services. SFHP was designed by and for the residents it serves, and takes great pride in its ability to accommodate a diverse population that includes young adults, seniors, and people with disabilities.
San Francisco Health Plan is proud to be an equal opportunity employer. We are committed to a work environment that supports, inspires, and respects all individuals and in which our processes are applied without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic origin, military service status, citizenship, or other protected characteristics.
Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.
San Francisco Health Plan is an E-Verify participating employer.