Medical Director

Gold Coast Health Plan will not sponsor applicants for work visas.

The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California.

Amount of Travel Required: 10%

Work Culture:

GCHP strives to create an inclusive, highly collaborative work culture where our people are empowered to grow and thrive. This philosophy enables us to create the health plan of the future and do our best work – Together.

GCHP promotes a flexible work environment. Employees may work from a home location or in the GCHP office for all or part of their regular workweek (see disclaimer).

GCHP’s focuses on 5 Core Values in the workplace:

• Integrity

• Accountability

• Collaboration

• Trust

• Respect

Disclaimer: Flexible work schedule is based on job duties, department, organization, or business need.

POSITION SUMMARY

The Gold Coast Health Plan Medical Director will be a physician responsible for providing clinical leadership to the Health Care Services Department, which includes management of the physician processes in support of utilization management, care management, pharmacy and associated transactional functions. These functions include performance of prospective, concurrent, retrospective utilization, member appeal and grievance reviews, and non-UM transactional work including but not limited to facilitating Gold Coast Health Plan’s interdisciplinary care team case conferences, Peer to Peer conference calls with network providers, assisting the Quality Improvement Department implement managed care accountability set (MCAS) initiatives, participating as a member of Gold Coast Health Plan’s UM, and Quality Committees, and providing retrospective provider claims dispute reviews.

The Medical Director is responsible for the day-to-day clinical determinations and transactional operations of Health Care Services. He/She is responsible for the monitoring and oversight of the UM functions performed within Health Care Services the delivery and review of defined metrics to validate business unit/program effectiveness and escalate to Gold Coast Health Plan’s Senior Medical Director the need for appropriate resources available to meet department needs and/or regulatory requirements. He/She is charged with ensuring compliance with requirements for all regulatory and accreditation authorities related to the department’s work and is responsible for ensuring departmental processes are applied and followed by Health Service associates who perform UM and transactional work.

The Gold Coast Health Plan Medical Director works collaboratively with Health Care Services and other appropriate Gold Coast Health Plan departments across product lines to identify and address opportunities to improve clinical quality, member satisfaction, reduce administrative cost and support department and organizational business goals. The Gold Coast Health Plan Medical Director will be responsible for engaging in organization-wide quality improvement efforts and promoting a culture of continuous improvement throughout the organization, and contracted provider partners.

Reasonable Accommodations Statement

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

ESSENTIAL FUNCTIONS

Key Responsibilities

These functions are ongoing and happen simultaneously. The Gold Coast Health Plan Medical Director should be comfortable multi-tasking, prioritizing responsibilities, and adapting to changes.

• Provide clinical and policy expertise for all aspects of physician UM serving as the representative on relevant projects including system implementation, service area and product expansion.

• Work together with the Health Care Service Senior UM Director, Senior Care Management Director, and Director of Pharmacy to monitor UM, CM and Pharmacy processes to identify opportunities for improvement and efficiency.

• Manage team-specific and/or departmental projects, as assigned by Gold Coast Health Plan Chief Medical Officer or the Gold Coast Health Plan Senior Medical Director.

• Escalate to Senior Medical Director, regulatory or public facing risks including root cause analysis and any corrective actions.

• Monitor quality, and reduction of targeted population health care inequities through the interpretation of UM, CM, and/or Pharmacy data and metrics.

• Together with the Health Services Senior UM Director, Senior CM Director, and Pharmacy Director review, revise and monitor policies and procedures to ensure that all work of the department meets all regulatory and accrediting standards for all products.

• Ensure all regulatory, operational and documentation standards and reporting needs are met.

• Manage day-to-day integration of technology to support department transactional functions.

• Establish and reinforce processes for implementing various inputs of information to support all lines of business including assessing and implementing new technology.

• Continuously work to identify and implement administrative efficiencies within the department.

• Serve as a clinical resource to both non-clinical and clinical Gold Coast Health Plan staff.

• Other duties as assigned.

Transactional Work

• Perform clinical review of prospective, concurrent, and retrospective coverage requests; and standard and expedited member appeals/grievances for in-patient and outpatient services requiring prior authorization and concurrent review.

• Provide physician support and leadership for the care management rounds and care planning activities for all lines of business as required.

• Participate in the Gold Coast Health Plan inter-rater reliability program.

• Perform provider claims dispute reviews.

• Provide physician expertise for the development/modification of claims payment rules.

• Participate in training of Gold Coast Health Plan Health Care Services staff.

• Participate in or lead relevant committee and staff meetings producing appropriate documentation and carrying out follow-up as needed to ensure business objectives are met.

• Serve as internal consultant/clinical resource to other departments as needed.

• Represent Gold Coast Health Plan in relevant external meetings and initiatives as assigned by the Gold Coast Health Plan Senior Medical Director and/or Gold Coast Health Plan Chief Medical Officer.

Staff Development

Create a team succession plan that provides opportunities for growth and ensures business process continuity.

• Be a resource to Gold Coast Health Plan and the Health Services Department for complex situations.

Quality

Work with Quality teams to improve quality scores (HEDIS and STARS)

• Meet regularly with the Quality Improvement team to review and adjust tactics to improve quality measurement performance.

• Participate in scheduled joint quality, and operations meetings with network provider groups quality measure progress, and collaborate with network providers to develop strategies and tactics for improved quality measurement performance.

• Review, analyze, and draft responses to member and provider grievances.

• Engage contracted providers with high frequency of member grievances.

Pharmacy

• Collaborate with the Gold Coast Health Plan Pharmacy department to provide clinical review of authorization requests.

MINIMUM QUALIFICATIONS

Education & Experience: Please identify the nature of education and experience such as: Associates, Bachelor’s and/or Master’s degree (four-year college or technical school) and list any applicable specialty or field of study.

• Doctorate Degree in Medicine.

• Board Certification in a medical specialty.

• Minimum 5 years previous Medical Director or equivalent medical leadership role.

• Minimum 5 years Utilization/Quality Program Management experience.

• Minimum 5 years clinical practice.

• Minimum 5 years HMO/Managed Care experience.

Preferred Experience:

• Peer Review, credentialing, quality improvement, medical policy/procedure development, provider contracting experience.

Equivalent In lieu of degree:

• Not applicable

KNOWLEDGE, SKILLS & ABILITIES

Preferred Qualifications:

• Working knowledge of population health management and/or health care inequities

• Masters Public Health Degree

Technology & Software Skills: Advanced computer skills in MS Office products.

Certifications & Licenses: A valid and current Driver's License, Auto Insurance, and professional licensure(s)

Competency Statements

• Management Skills - Ability to organize and direct oneself and effectively supervise others.

• Business Acumen - Ability to grasp and understand business concepts and issues.

• Decision Making - Ability to make critical decisions while following company procedures.

• Goal Oriented - Ability to focus on a goal and obtain a pre-determined result.

• Interpersonal - Ability to get along well with a variety of personalities and individuals.

• Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.

• Time Management - Ability to utilize the available time to organize and complete work within given deadlines.

• Consensus Building - Ability to bring about group solidarity to achieve a goal.

• Relationship Building - Ability to effectively build relationships with customers and co-workers.

• Presentation Skills - Ability to effectively present information publicly.

• Delegating Responsibility - Ability to allocate authority and/or task responsibility to appropriate people.

• Leadership - Ability to influence others to perform their jobs effectively and to be responsible for making decisions.

• Strategic Planning - Ability to develop a vision for the future and create a culture in which the long-range goals can be achieved.

• Ethical - Ability to demonstrate conduct conforming to a set of values and accepted standards.

• Judgment - The ability to formulate a sound decision using the available information.

• Communication, Oral - Ability to communicate effectively with others using the spoken word.

• Communication, Written - Ability to communicate in writing clearly and concisely.

• Problem Solving - Ability to find a solution for or to deal proactively with work-related problems.