SUMMARY: The Medical Director of Ambulatory Care interacts with physicians, staff, health plan staff, Associate Medical Directors, and health plan members when a physician's input is needed or required. The Medical Director of Ambulatory Care is responsible for the Medical Management functions that include Referral Management, Case Management, and Disease Management Programs, as regulatory agencies require and the IPA's health plan contracts stipulate. Medical Director shall work collaboratively with the Clinical Service Department to achieve the strategic goals of the department and Monarch HealthCare.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.
1. REFERRAL MANAGEMENT
a. Perform, or when necessary and appropriate, delegate to an Associate Medical Director, the daily review of authorization requests requiring a physician's decision regarding appropriate care.
b. Be the final decision maker for the IPA on any denial of payment for outpatient services.
c. Monitor ambulatory care utilization trends, communicate to the IPA leadership and providers, and make recommendations to position the organization proactively to manage trends effectively.
d. With the staff, develop and implement action plans, including clinical guidelines, to ensure clinically appropriate and efficient utilization of services.
e. Provide and /or supervise the education, guidance, assistance, and feedback to primary care physicians and specialty panels to achieve appropriate cost-effective patient care.
f. Assess provider network for adequacy of services and make recommendations to staff to address service gaps.
2. CASE/DISEASE MANAGEMENT and OTHER SPECIAL PROGRAMS
a. Oversee program implementation and ongoing case and disease management programs, interfacing with case managers and other staff for medical advice and intervention as needed.
b. Monitor utilization trends and communicate program outcomes to IPA leadership and physicians.
c. Promote the appropriate utilization of programs to manage complex and/or catastrophic cases and to promote positive health outcomes through disease management interventions.
3. COMMITTEE FUNCTIONS AND LEADERSHIP
a. Chairperson of the Utilization Management Committee, supervises Ambulatory Care Associate Medical Directors or community physician designees.
b. Chairman of UM Subcommittee
c. Medical Director Lead for identified clinical initiatives or project teams as appropriate
d. Ensures that Ambulatory Care AMDs have appropriate training regarding clinical guidelines with interrater reliability
e. Member of the Quality Management Committee.
f. Provide direction to the staff regarding the agenda and schedule of clinical committee meetings; assist as needed in preparing the necessary materials to conduct the meetings.
g. Attend and provide clinical presentations at IPA Board meetings, General Membership meetings, the Medical Leadership Council, and Physician Advisory committees.
h. Develop educational programs for the physician network to enhance the delivery of patient care.
4. NETWORK MANAGEMENT/PROVIDER CONTRATING
a. Identify gaps in the IPA network and assist in identifying and recruiting new providers.
b. Facilitate collegial provider relations with the IPA physicians and general medical community. Provides feedback and education to IPA physicians regarding UM Initiatives
c. Act as the main point of contact for physicians who wish to speak directly about authorization requests and follow up information.
d. Assess the adequacy of information being provided by the IPA to the IPA's providers and assist in development of any new or revised materials.
e. Attend periodic health plan and hospital meetings on issues pertaining to the IPA as needed.
f. Assist staff from a clinical perspective in development of fee schedules or payment methodologies.
g. Works collaboratively with the Medical Director of Quality to provide clinical input required for the staff to create and deliver physician performance reports to enhance performance of the physician network.
5. HEALTH PLAN RELATIONS
a. Establish and foster strong working relationships with the health plan Medical Directors
b. Interact with health plan medical directors on specific cases as needed.
6. CLAIMS/REVENUE RECOVERY
a. Assist claims processing staff in review of medical claims for unbundling of services or other inappropriate billing practices.
b. Assist claims and revenue recovery staff by reviewing and authorizing cap deductions.
7. MEMBER SERVICES
a. Assist the IPA member services staff when necessary in resolving individual member complaint issues.
b. Review member services trend activity and interact with individual providers as necessary.
a. Provide assistance in analysis of medical cost trends. Formulate and make recommendations from a clinical perspective based upon these analyses.
b. Interact with staff to develop reports to monitor medical costs and formulate recommendations from a clinical perspective based upon these analyses.
a. Regular and consistent attendance.
b. Serves on committees external to Monarch HealthCare, as deemed appropriate
EDUCATION and/or EXPERIENCE:
1. Possess the education, training, and professional experience in medical or clinical practice to evaluate specific clinical issues to make medical necessity determinations and to make decisions that deny or modify necessity determinations and to make decisions that deny or modify services based on medical necessity.
2. Possess sufficient clinical knowledge to interact with the physician members of the IPA in all major medical specialties.
3. Have at least three years of clinical practice in direct patient care; and at least three years medical management experience in a managed care setting.
LICENSES, CERTIFICATES, REGISTRATIONS:
1. The Medical Director of Ambulatory Care must hold a valid, unrestricted license to practice medicine in the State of California.
2. Board certification in the chosen specialty.
Ability to read, analyze, and interpret the most complex documents. Ability to respond effectively to the most sensitive inquires or complaints. Ability to write speeches and articles using original or innovative techniques or style. Ability to make effective and persuasive speeches and presentations on controversial or complex topics to top management, public groups, and/or boards of directors.
Ability to work with mathematical concepts such as probability and statistical inference, and fundamentals of plane and solid geometry and trigonometry. Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.
Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.
OTHER SKILLS and ABILITIES:
Advice, mentor, and provide medical information to all Clinical Services clinical and non-clinical staff. Acts as a resource to the Clinical Services department.
Ambulatory Care Associate Medical Directors
PHYSICAL DEMANDS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is required to regularly walk, sit, use hands to finger, handle or feel, talk or h
Skills / Requirements