Responsible for medical direction in medical quality; utilization management; and health education. This includes oversight responsibility for the delivery of medical services for members covered under OneCare, Quality Improvement projects and new programs. Ensures quality medical service delivery to members for the fee-for-service health plan managed directly by CalOptima’s Special Needs Plan. Manages medical aspects of contracts for services, oversees authorization for service and quality assurance for OneCare.
Possess the Ability To:
- Provide leadership in the medical care delivery system and participate in the development and implementation of strategies, programs, policies and procedures for medical services. Collaborate in program evaluation and implementation of strategies, programs, policies and procedures for medical services.
- Ensure appropriate policies and procedures for medical service delivery in OneCare and CalOptima Direct.
- Ensure policies and procedures are compliant with regulatory and accreditation requirements.
- Oversight responsibility for OneCare’s Model of Care.
- Oversight responsibility for the delivery of medical services for OneCare members.
- Provide medical direction for the OneCare program.
- Manage medical aspects of contracts for services, oversees authorization for service and quality assurance for OneCare.
- Oversee the utilization management functions for OneCare.
- Conduct medical case review, medical project development, and medical/nursing staff development.
- Review complex cases and participate in the Interdisciplinary Team (IDT) process.
- Consultant and conduit for the delegated entities.
- Review, make recommendations and monitor medical related aspects of the OneCare Provider Network Contracts.
- Establish standards for evaluating providers for inclusion in OneCare program and for the on-going performance of participating providers and interface with medical providers in the OneCare network.
- Review of all appeals and second level provider grievances for OneCare, CalOptima Direct and OneCare Physician Medical Groups.
- Participate in the State Fair Hearing process.
- Provide management support to the department of Health Promotion and Wellness.
- Supervise the development and implementation of health education activities.
- Chair the Clinical Quality Improvement Committee.
- Quality Improvement projects and new programs.
- Oversee quality case review issues for OneCare and CalOptima.
- Provider education regarding Clinical Practice Guidelines.
- Serve as a liaison between CalOptima and the County Organized Health Systems with the State Department of Health Services and the Managed Risk Medical Insurance Board.
- Manage medical aspects of contracts for services, oversee authorization for service and quality assurance for OneCare.
- Other projects and duties as assigned.
Experience & Education
- Manage a large point of services and network of providers.
- Develop and implement appropriate medical service contracts and monitor compliance.
- Plan, organize and direct utilization review, quality management, case management, and health education and grievance activities.
- Ensure appropriate and cost effective medical care and service to members not covered by a contracted health plan.
- Establish and maintain effective interpersonal relationships with all levels of staff, other programs, agencies, and the general public.
- Effectively utilize computer and appropriate software and interact as needed with CalOptima Information Systems.
- Current, valid, unrestricted California Physician & Surgeon’s License with Board certification in area of specialty.
- Considerable experience in medical management, quality management, and utilization management in a managed care setting.
- Experience handling the care of seniors and persons with disabilities.
- Medical diagnoses and appropriate treatment.
- Industry and professional standards of health care, utilization management, quality improvement and other medical management functions.
- Fee-for-service and managed care service delivery systems.
- Medi-Cal benefits and regulations, as well as its population and demographics.
- Provider network requirements to provide appropriate service and access for a large population with complex medical needs.
- Principles and practices of healthcare, health care systems, and medical administration.