Medical Director - D-SNP

Description

Central Coast Salary Range: $281,107 - $449,771 Annually

Job Summary

Candidates for this position must reside on the Central Coast (Ventura, Santa Barbara, San Luis Obispo, Monterey, and Santa Cruz Counties) or be willing to relocate to the area upon hire. As a community-facing role, a local presence is essential to effectively engage with and serve our community. Please note that relocation assistance may be available.

The Medical Director for D-SNP, reporting to the Chief Medical Officer (or their designee) or Director of Dual D-SNP Clinical Programs (or their designee), is primarily responsible for overseeing D-SNP clinical functions, including utilization management, appeals and grievances, quality, care management and coordination, provider relations, and credentialing. Additionally, this role shares responsibility for overseeing the clinical aspects of utilization, quality, care management, and credentialing within the Medi-Cal program. The Medical Director ensures the delivery of high-quality healthcare, supports organizational objectives, and ensures compliance with contractual and regulatory requirements. This role involves diverse and complex responsibilities, requiring significant discretion and independent judgment. While the focus is primarily on CenCal Health’s D-SNP members and their service needs, the position may be performed on a hybrid or remote basis, depending on business needs.

Duties and Responsibilities

• Subject Matter Expertise: Stays current with emerging trends, federal and state policies, and initiatives affecting the D-SNP program and the care provided to dual-eligible beneficiaries. Serves as the subject matter expert on D-SNP clinical priorities and initiatives.

• Provider Engagement: Acts as CenCal Health’s physician liaison for the D-SNP provider network, fostering relationships with providers, provider organizations, and stakeholders to support contracting, provider relations, marketing, and other D-SNP program objectives. Contributes medical director insights during Interdisciplinary Care Team meetings and, under the guidance of the D-SNP Director for Clinical Programs, assists in creating educational resources (videos, training, documents) for providers.

• Organizational Collaboration: Works closely with the Chief Medical Officer (CMO), other medical directors, and the Director of D-SNP Clinical Programs to identify medical service issues impacting plan benefits, develop action plans, and track progress. Participates in committees such as Credentialing, Peer Review, Pharmacy & Therapeutics, Quality Improvement, and/or Joint Operating Committee (JOC) meetings, as needed.

• Data and Quality Analysis: Identifies and analyzes quality issues and trends, offering recommendations and implementing agreed changes. Engages in special projects related to NCQA certification and the implementation of the Medicare D-SNP line of business. Partners with stakeholders to gather and analyze data on dual-eligible beneficiaries, ensuring alignment with D-SNP program goals and regulations. Works to streamline data collection, measurement, and performance monitoring to ensure compliance with D-SNP requirements.

• Clinical Expertise: Provides clinical oversight, developing care management strategies with the Director of D-SNP Clinical Programs and the CMO (or their designee). Collaborates with the Case Management team to review complex cases, evaluate outcomes, and ensure D-SNP members receive appropriate and cost-effective care. Offers clinical guidance on resolving complex administrative issues and leads medical management functions, including addressing issues related to medical claims review, utilization, grievances, appeals, and other concerns.

• Utilization Management and Medical Necessity Review: Maintains a prior authorization list for D-SNP utilization management and develops pathways to assess care requests based on utilization management principles and medical necessity. Upon D-SNP go-live (01/01/2026), the Medical Director will conduct clinical reviews and make UM decisions for prior, concurrent, and retro authorizations, as well as appeals, based on medical necessity and CenCal Health’s criteria. Works with providers and collaborates with Health Services to develop UM policies and procedures.

• Pharmacy Liaison for D-SNP: Collaborates with the Pharmacy team to assess the clinical appropriateness of medication utilization and drug usage patterns. Presents D-SNP pharmacy issues and trends to the CenCal Health Pharmacy & Therapeutics (P&T) Committee.

• Interdisciplinary Care Team Support/Population Health Initiatives: Partners with the ICT to develop care plans that address the medical, behavioral, and social needs of D-SNP members, improving both individual and population health outcomes. Supports population health strategies such as preventive care, chronic disease management, and healthcare disparity reduction to enhance D-SNP members' overall health outcomes.

• Risk Management: Identifies potential risks and opportunities within the D-SNP program, working with the D-SNP Director/CMO (or their designee) to develop action plans that meet strategic targets. Escalates high priority issues and identifies improvement opportunities.

• Provider Engagement: Actively participates in provider meetings, training, and quality improvement initiatives, offering clinical expertise and guidance to enhance care delivery. Supports providers in implementing evidence-based guidelines and clinical standards.

• Medi-Cal Program Support: This position will also support the Medi-Cal Program similarly, including on-call responsibilities related to post-stabilization care services.

Qualifications

Knowledge/Skills/Abilities

Required:

•    Extensive knowledge and experience with government-sponsored healthcare programs, including Medi-Cal and Medicare.
•    In-depth understanding of managed care principles and practices, with particular expertise in utilization management, appeals and grievances, case management, and discharge planning.
•    Comprehensive knowledge of the healthcare, economic, and social factors that impact Medi-Cal and Medicare populations, providers, and underserved communities in Santa Barbara, San Luis Obispo counties, and the surrounding regions.
•    Focus on continuous process improvement and driving organizational efficiency across all projects.
•    Strong ability to identify, implement, and monitor key metrics and models, using data-driven insights to apply effective interventions.
•    Experience with analyzing and critiquing healthcare contract components and language, ensuring thorough understanding and compliance.
•    Expertise in audit, control, and monitoring processes, with a proven track record of effective implementation and maintenance.
•    Solid understanding of population health concepts and the impact of social determinants on health outcomes.
•    Outstanding facilitation, problem-solving, and conflict resolution abilities.
•    Proven ability to develop, execute, and track strategic and business plans in collaboration with the Director of D-SNP Clinical Programs.
•    Strong collaboration skills, with a track record of fostering a team-oriented work environment and organizing resources to address challenges and seize opportunities.
•    Excellent interpersonal skills, able to build and maintain effective relationships at all levels both within and outside of CenCal Health. Skilled in team building and developing consensus.
•    Exceptional oral and written communication skills, with the ability to convey information clearly and persuasively to diverse individuals and groups, both internally and externally.
•    Strong presentation skills, with the ability to tailor content to specific audiences and engage large groups effectively.
•    Commitment to aligning with and promoting organizational values, integrating them into management practices and encouraging staff to do the same.
•    Customer service-focused, with a dedication to meeting the needs of internal and external stakeholders.
•    Excellent project management skills, with the ability to manage multiple tasks and priorities effectively.
•    Proficient in Microsoft Word and Excel, with strong technical capabilities.
•    Fluent in English, both spoken and written.
•    Demonstrates discretion and integrity in handling confidential information.
•    Adaptability to changing requirements, with openness to new approaches and a willingness to modify personal preferences when necessary.
•    Willingness to travel as needed, including occasional visits to provider offices, healthcare facilities, or CenCal offices in Santa Barbara/SLO for business functions such as in-person trainings, provider engagements, or educational content creation.
•    Consistently attends meetings on time, prepared, and actively contributes to business objectives.
•    Accountable for follow-through on all actions, demonstrating integrity and responsibility in all decisions and behaviors.
•    Ensures accuracy and completeness of work and information, preparing for meetings and presentations meticulously, and following up to ensure that agreements and commitments are fulfilled.

Education and Experience

Required:

• Current California Medical License issued by the Medical Board of California, with an unrestricted ability to practice medicine in the state, and meeting the Health Plan’s credentialing and re-credentialing standards.

• Board certification in a relevant specialty from an accredited body, with a preference for Internal Medicine or Family Practice.

• MD/DO degree from a medical school accredited by a U.S. institution.

• Successful completion of a residency program accredited by the American Council of Graduate Medical Education (ACGME) or the American Osteopathic Association (AOA).

• At least three to five (3-5) years of clinical experience in the practice of medicine.

• A minimum of 3-5 years of experience in Medi-Cal and Medicare Utilization Management/Case Management within a health plan, IPA, or similar medical management organization.

Salary : $281,107 - $449,771