Role Description This is a remote position. Must reside in California. Under limited supervision, the Medical Director is responsible for providing clinical oversight of the Health Plan’s utilization, quality, pharmacy, and credentialing and health equity functions in a manner that ensures the delivery of quality, cost-effective healthcare, supports organization objectives, and meets contractual, accreditation, and regulatory requirements. The position supports the grievances and appeals team with clinical oversight of grievances and quality of care investigations and resolutions. Work is varied and highly complex and requires a moderate to high degree of discretion and independent judgment. Essential Functions - 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 Deputy CMO (DCMO) to identify medical service issues that have an impact on plan benefits and their administration, develop action plans and monitor results. - Identifies and analyzes care and 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. - Conducts clinical reviews and makes UM decisions for prior, concurrent, and retro authorizations, and appeals; approves/denies or offers medical alternatives according to HPSJ’s medical review criteria for both Medi-Cal and Dual Eligible Special Needs Plan (DSNP) members. - Conducts reviews of grievances and quality of care issues for both Medi-Cal and DSNP members; identifies opportunities for improvement and works with both internal and external stakeholders to improve care and services. - Provides expertise and guidance for activities related to improving quality and health equity metrics. - Establishes and maintains working relationships with providers, provider organizations and other stakeholders that supports contracting, provider relations, marketing and other organizational goals and objectives. - Collaborates with leadership to ensure medical compliance with internal, regulatory and accreditation requirements. - Provides medical expertise and direction for clinical policies, procedures, and programs. - Serves on Quality Improvement & Health Equity Committee, Peer Review and Credentialing Committee, Grievance and Appeals Committee, Clinical Operations Committee and Physician Advisory Committees; serves on other committees as required. - Represents HPSJ in a manner that promotes a positive image of HPSJ in the community. - Assists with development of corporate and department budgets and metrics. Qualifications - In-depth knowledge of the principles and practices of managed care related to utilization management and/or case management and/or discharge planning. - In-depth knowledge of the healthcare, economic or other issues affecting Medi-Cal and/or Medicare populations, providers and the underserved in San Joaquin and surrounding areas. - Basic knowledge of managed healthcare as applied to government sponsored programs including Medicaid and SCHIP. - Strong knowledge of and ability to identify, implement, monitor and analyze relevant metrics models, and implement effective interventions based on results. - In-depth knowledge of standard contract components and contract language specific to healthcare. - In-depth knowledge of audit, control and monitoring processes, and the ability to effectively implement and maintain them. - Financial acumen: Interprets and applies understanding of key financial indicators to make better business decisions. - Strong skills in budget development and management. - Manages complexity: Makes sense of complex, high quantity, and sometimes contradictory information to effectively solve problems. - Decision quality: Makes good and timely decisions that keep the organization moving forward. - Strategic mindset: Sees ahead to future possibilities and translates them into breakthrough strategies. - Ability to execute and monitor relevant strategic and business plans. - Resourcefulness: Secures and deploys resources effectively and efficiently; organizes people and resources to solve problems and identify opportunities. - Plans and aligns: Plans and prioritizes work for self and others to meet commitments aligned with organizational goals. - Ensures accountability: Holds self and others accountable to meet commitments. - Drives results: Consistently achieves results, even under tough circumstances. - Strong collaboration skills with demonstrated ability to create and foster a collaborative work environment, maintain effective, high-performance teams, and organize people and resources to solve problems and identify business opportunities. - Very strong interpersonal skills, with the ability to establish and maintain effective working relationships with individuals at all levels inside and outside of HPSJ. - Very strong oral and written communication skills, with the ability to communicate professionally, effectively, and persuasively to diverse individuals and groups inside and outside of HPSJ. - Strong presentation skills, including the ability to tailor presentations to a specific audience, and address and interact with large groups. - Builds networks: Effectively builds formal and informal relationship networks inside and outside of the organization. - Organizational savvy: Maneuvers comfortably through complex policy, process, and people-related organizational dynamics. - Persuades: Uses compelling arguments to gain the support and commitment of others. - Manages ambiguity: Operates effectively, even when things are not certain, or the way forward is not clear. - Manages projects and deliverables on time and on budget. - Promotes and maintains and ensures that direct reports promote and maintain an environment that supports HPSJ’s strategy, vision, mission, and values. - Intermediate skills in Word and Excel. - Ability to speak and be understood in English. - Ability to handle confidential information with appropriate discretion. Education and Experience - MD degree from an accredited medical school. - Satisfactory completion of an American Council of Graduate Medical Education accredited residency program. - At least five years clinical experience in the practice of medicine in fields related to a managed care setting. A Master’s Degree in Public Health may be substituted for two years of the required clinical experience. - At least five years clinical experience in the practice of medicine with Medi-Cal and/or Medicare populations. - At least five years supervisory experience in a healthcare setting; or equivalent combination of experience. Licenses, Certifications - Unrestricted license to practice medicine in the State of California, issued by the State Board of Medical Examiners, which meets the Health Plan’s credentialing and re-credentialing requirements. - Board Certification in a chosen specialty. - Valid California driver license and reliable transportation or, the ability to obtain transportation on demand in the counties served by HPSJ if prohibited from getting a driver license due to a medically documented disability. Benefits - Robust and affordable medical coverage including HMO and PPO plan options. - Employee Wellness Program promoting physical, mental, and financial well-being. - Dental and vision plan with multiple provider choices. - Generous paid time off (accrue up to 3 weeks of PTO, 4 paid floating holidays, and 9 paid holidays). - CalPERS retirement pension program, automatic employer-paid retirements contributions, plus a voluntary defined contribution plan. - Two flexible spending accounts (FSAs) for healthcare and dependent care expenses. - Employer-Paid Term Life and AD&D Insurance. - Employer-Paid Disability Insurance. - Employer-Paid Assistance Program (EAP). - Health Advocacy to help you navigate medical care and benefits. - Voluntary supplemental benefits including medical, legal, identity theft protection. - Online discount mall. - Tuition reimbursement. - Remote work contingent on business needs and company guidelines. - A chance to work for an organization that is mission-driven – our members and community are at the core of everything we do. Physical Demands Work may require frequent sitting, standing, and walking, constant repetitive motion, frequent talking and listening, closeup and distance vision requirements. Some work may require occasional travel based on the responsibilities of the position and business needs and occasional handling materials up to 50 pounds. Emotional/Psychological Demands Ability to cope with a fast-paced work environment, working under pressure, dynamic priorities and deadlines, constant decision making, working irregular hours, emotional and sensitive situations. Work Environment Work may be performed in a remote, hybrid, or onsite setting depending on the requirements of the position and business needs. For roles performed remotely, employees are expected to maintain a secure, distraction-free workspace, and reliable internet connectivity consistent with company standards. Important Notice The duties, qualifications, and physical and emotional requirements listed in this job description are not exhaustive. Health Plan of San Joaquin reserves the right to revise this job description at any time.

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