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Senior Medical Director, San Francisco, CA


Organization: San Francisco Health Plan
Category: Medical Director
Location: San Francisco, CA
Date Job Posted: January 12, 2023
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Senior Medical Director

Department: Clinical Operations Administration
Salary Range: $299,000 - $333,000 annually

Under the direction of the Chief Medical Officer, the Senior Medical Director is responsible for clinical oversight and management of all SFHP Utilization Management (UM) and Quality Improvement functions. The Senior Medical Director works in partnership with VP 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.

  • 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 Program.
  • Provide leadership and oversight in Quality Improvement strategy, including HEDIS and CAHPS.
  • 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.
  • Lead and develop Quality Improvement strategy around HEDIS and CAHPS, in collaboration with the Population Health Management team.
  • Consult and advise on the development of protocol, procedures, oversight and training in the following areas:
    • Pharmacy
    • 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 Participates and provides physician leadership in the following SFHP Committees.
    • Utilization Management Committee
    • Grievance Review Committee
    • Pharmacy and Therapeutics Committee
    • Quality Improvement Committee
    • Participates on the Pharmacy and Therapeutics Subcommittee
    • NCQA Accreditation
  • Provide physician leadership and clinical support for the following areas: Grievance and Appeals, Care Management, Potential Quality Issues.
  • 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.

DIRECTOR-LEVEL EXPECTATIONS:

Strategic Thinking & Functioning

  • Digests systems and complexity comfortably is able to communicate ideas and understanding with precision and simplicity
  • Possess a well of physical, emotional and mental stamina; knows self well and functions very effectively
  • Anticipates events and trends and identifies potential obstacles; resilient and resourceful, preservers and persists
  • Brings a broad perspective, emotional maturity, and empathy to support effective decision making, clarity, and efficiency throughout the organization

Dealing with Ambiguity & Creativity

  • Motivated by challenges, adversity, the unknown and intensity
  • Takes risks and the initiative and applies innovative thinking to analyze and support strategic decision making throughout the organization
  • Able to integrate new information quickly and seamlessly; listens to others and understands deeply;
  • Embraces and champions change to support continuous improvement

Engaging Others and Building a Healthy Environment

  • Able to forge strong relationships with external stakeholders including providers DPH, LHPC, etc.
  • Connects with others and builds relationships with ease, authenticity and respect
  • Engages effectively with all levels of the organization knowing when to lead, manage and get out of the way; allows others to do the same
  • Transparent and direct; encourages healthy conflict; can take tough stands and make tough calls; prioritizes the needs of the organization
  • Handles adversity with grace and maintains a balanced approach to serve the needs of everyone involved

Organization & Leadership Development

  • Coaches and mentors his/her/their team with an eye on Succession Planning and Leadership Development for the entire organization; actively seeks out feedback and makes self-development a priority
  • Integrates Talent Management as part of the ongoing agenda
  • Attracts and inspires others including staff, board, and partners

Community Leadership

  • Represents SFHP as a role model Health Plan and supports sister plans in leveraging best practices, etc.; is a leader in the Community
  • As primary spokesperson and public face for the organization, promotes, advocates and builds relationships critical to the success of SFHP

WHAT YOU WILL BRING

  • 5 years of post-residency experience in a recognized medical specialty, which must have included at least (3) years of managed care experience. Preferred experience is in adult primary care, such as family practice or internal medicine.
  • Experience working with clinical practice guidelines and evidenced based criteria sets.
  • Experience leading Quality Improvement efforts.
  • Possesses strong knowledge of Managed Care principles, utilization and case management programs and has exposure to working with regulatory agencies.
  • Knowledge of CMS and Medicaid regulations preferred; Medical Director for an IPA, medical group or HMO highly desirable
  • MD/DO degree from an accredited program, with an active, unrestricted California medical license.
  • Board certification.
  • A current CA license to practice without restriction.
  • 3-5 years of supervisory/management/leadership experience in managed care setting
  • Experience in delivery and implementation of Utilization Management and Quality initiatives.

Candidates will be required to show proof of Up-To-Date Vaccination against COVID-19 as defined by the San Francisco Department of Public Health upon beginning employment. Reasonable accommodations will be considered on a case-by-case basis for exemptions to this requirement subject to the applicable law[s].

WHAT WE OFFER

A competitive and robust compensation package, including:

  • Health benefits – several plan choices to cover you and your dependents medical, dental, vision needs
  • Retirement – Employer-matched CalPERS Pension and 401(a) plans, 457 Plan
  • Time off – 23 days of Paid Time Off (PTO) and 13 paid holidays
  • An opportunity to work in a vibrant atmosphere with the most amazingly talented people who are shaping the future of healthcare!
  • The chance to make a difference in the lives of many San Francisco residents!

ABOUT US

Established in 1997, San Francisco Health Plan (SFHP) is 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 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.

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