The primary purpose of this position is to provide medical management leadership and direction for American Specialty Health Specialty Network programs (with a focus on Physical Medicine and related clinical services) through personal hands-on involvement in day-to-day medical management decision making and through leadership and management of the medical management team.
o Medical oversight and medical decision-making.
- Provide Medical Oversight and Medical Management: Medical management support to the Senior Vice President, Chief Health Services Officer, and Chief Executive Team members, and clinical and administrative staff as required.
- Supports review and authorship of RFP documents and other marketing or sales activities as requested by CEO and CHSO.
- Develops and authors business specifications documents, guidelines, and other infrastructure policies and procedures in collaboration with Key Process Teams and Clinical Committees.
- Provides medical support and clinical decision-making to support ASH Group products directed by CEO and CHSO and Sr VP Clinical Services.
o Authorship of specifications documents; guideline drafts; clinical decision-assist criteria and other documents required to execute the duties of the position.
o Supports Clinical Quality Administration functions including building and documenting systems for medical management components of the programs.
o Reviews quality cases and makes medical management decisions.
o Oversees clinical quality activities as required including review quality.
o Contributes to product and process development, implementation and management.
o Provides medical editing and supports document development.
o Supports clinical evidence review committees and quality committees as assigned.
o Supports development of medical risk management Supports external medical relationships to support ASH goals.
o Provides connection to the medical industry (e.g. Medical Associations).
o Provides support to budgeting; planning; corporate development.
o Assists with coordinating and collaborative projects that involve medical decision-making.
o Supports design, implementation and monitoring of clinical QI initiatives.
o Contributes to Evidence Evaluation Committee research and guideline development activities.
o Cross-functional collaboration with operations and other administrative teams through Line of Business; Key Process Teams, and committees Contributes to design, analysis, and communication of health outcomes measurement metrics.
o Provides medical expertise to ASH health services research initiatives.
o Management of field based MD support and provides backup appeals review support.
o Provides oversight, supervision and management of assigned staff.
o Oversight of performance and clinical review by consulting medical physicians.
o Provides staff training as required.
o Provides coaching, training, annual performance reviews for staff.
- Escalates risk management concerns to Senior Management.
- Obtains and maintains Medical Doctor credentials active, unencumbered, and in good standing.
- Obtains and maintains Medical Doctor state licenses in states required by ASH business needs.
- Maintains clinical knowledge and expertise in clinical fields applicable to job duties and Board Certifications.
- Performs other duties and responsibilities as assigned.
- Graduate of an accredited medical college and Board certified. Must have a current, unrestricted medical license in the state of California and be able to obtain state medical licenses in other states as needed.
- Active Board Certification in Orthopedics or Physical Medicine and Rehabilitation or Pain Management issued by an accepted medical Board.
- Minimum 8 years of clinical practice experience required.
- Experience as full-time medical director for a full-service medical health plan / insurance company.
- Supervisory experience including design and operations of medical management systems and processes within an NCQA and/or URAC accredited Health Plan.
- Experience in Disease Management, Care Coordination, Utilization Review, Clinical Quality Improvement, Clinical Coding, Network Management, Health Information Technology, and Credentialing experience preferred.
- Valid Driver’s license with good driving record. Availability of automobile for on the job use and proof of insurance.
Mobility - Primarily sedentary, able to sit for long periods of time.
- Excellent communication skills and computer skills.
- Excellent medical management skills.
- Able to succeed in a very dynamic, rapidly changing, and entrepreneurial organization.
- Demonstrated ability to collaborate and work with practitioners of other disciplines and within a wide body of clinical evidence.
- Demonstrated ability to interact in a positive, respectful m a nner and establish and maintain cooperative working relationships.
- Desire to learn new systems and effectively integrate new ideas into established systems and product designs
- Ability to display excellent customer service to meet the needs and expectations of both internal and external customers.
- Excellent listening and interpersonal communication skills to identify critical core competencies based on success factors and organizational environment.
- Ability to effectively organize, prioritize, multi-task and manage time.
- Demonstrated accuracy and productivity in a changing environment with constant interruptions.
- Demonstrated ability to analyze information, problems, issues, situations and procedures to develop effective solutions.
Physical Requirements - Ability to speak, see and hear other personnel and/or objects. Ability to communicate both in oral and written form. Capable of using a telephone and computer keyboard. Ability to lift up to 10 lbs. Ability to travel within the facility. Ability to drive and travel by air.
Environmental Conditions - Usual office setting.