Under the general direction of the Chief Executive Officer (CEO), the Medical Director is responsible for providing clinical strategic direction and oversight for AmericasHealth Plan (AHP). The position oversees medical care delivery system, including development and implementation of strategies, programs, policies and procedures for all medical services. The CMO works with management, medical staff, the board and other constituents to influence thinking and recommend policy and strategic direction.
Essential Functions AND Responsibilities
Provides oversight of medical decisions for AHP.
Establishes standards for evaluating providers for inclusion in the AHP Network and for the on-going performance of participating providers.
Responsible for determinations of medical necessity and appropriateness of medical services.
Analyzes accessibility and utilization issues and implements strategy to overcome barriers.
Assist in selection of participating health plans, ancillary services and other providers.
Ensure establishment of appropriate mechanisms to provide final medical judgment on claims appeals/denials.
Education, Experience AND Qualifications
Board eligible or certified in area of specialty. MD/DO degree from an accredited college or university. Possession of a valid, unrestricted license to practice medicine issued by the California State Board of Medical Examiners.
Prior administrative and managed care experience including Medi-Cal/Medicare.
Thorough medical and administrative knowledge in analyzing and coordinating healthcare activities.
Job Type: Part-time
health plan, ipa, or medical group environment: 1 year (Preferred)
managed care Medi-Cal/Medicare: 1 year (Preferred)
medical director, or equivalent executive/administrative: 1 year (Preferred)