Medical Director - Temporary

Description

Central Coast Hourly Range:  $135.15 - $216.24 Per hour

Job Summary

The Medical Director, reporting to the Chief Medical Officer or their designee, is responsible for overseeing clinical functions related to utilization, quality, care management, and credentialing. This role ensures the delivery of high-quality healthcare, supports organizational goals, and complies with contractual and regulatory requirements. The work is diverse and complex, requiring a significant degree of discretion and independent judgment. The position will primarily focus on CenCal Health’s adult members and their service needs. This role may be performed on a hybrid or remote schedule, depending on business needs.

Duties & Responsibilities

• Provides clinical leadership for medical management functions, assisting subordinate managers in addressing issues related to medical claims review, grievances, appeals, and other medical management concerns.
• Collaborates closely with the Chief Medical Officer (CMO) and other medical directors to identify medical service issues impacting plan benefits and their administration, develop action plans, and monitor progress.
• Identifies and analyzes quality issues and trends, making recommendations based on findings, and developing and implementing agreed-upon changes.
• Offers clinical expertise to effectively resolve complex, controversial, or unique administrative situations, working with both internal and external teams.
• Conducts clinical reviews and makes utilization management (UM) decisions for prior, concurrent (hospital/skilled nursing facility), and retro authorizations, as well as appeals. Approves/denies requests for care and services based on CenCal Health’s medical review criteria. Engages with providers as needed by phone or in person and develops UM policies and procedures in collaboration with Health Services staff.
• Collaborates with the Pharmacy team to assess the clinical appropriateness of medication utilization.
• Builds and maintains relationships with providers, provider organizations, and other stakeholders to support contracting, provider relations, marketing, and other organizational objectives.
• Focused on process improvement and organizational efficiency.
• Provides clinical oversight and develops care management strategies and opportunities.
• May support population health initiatives.
• Currently has no direct reports but may supervise Health Services staff in the future.
• May participate in committees such as Credentialing, Peer Review, Pharmacy & Therapeutics, Quality Improvement, and/or Joint Operating Committee (JOC) meetings.
• Takes on other duties as assigned, including on-call responsibilities for post-stabilization care services.
• May participate in special projects related to NCQA certification and the implementation of the Medicare D-SNP line of business.

Qualifications

Knowledge/Skills/Abilities:

Required:

• Extensive knowledge of managed care principles and practices, particularly in utilization management, case management, and discharge planning.
• Understanding of healthcare, economic, and other factors affecting Medi-Cal and/or Medicare populations, providers, and underserved communities in Santa Barbara, San Luis Obispo Counties, and surrounding areas is preferred.
• Basic knowledge of managed healthcare, specifically as applied to government-sponsored programs including Medicaid and Medicare.
• Strong ability to identify, implement, monitor, and analyze key metrics and models, and apply effective interventions based on findings.
• Knowledge of standard healthcare contract components and language such as regulatory requirements within Medi-Cal and/or Medicare.
• Expertise in audit, control, and monitoring processes, with the ability to implement and maintain them effectively.
• Understanding of population health concepts and social determinants of health.
• Exceptional facilitation, problem-solving, and conflict resolution skills.
• Ability to develop, execute, and monitor relevant strategic and business plans.
• Strong collaboration skills with a proven ability to foster a team-oriented work environment, maintain high-performance teams, and organize people and resources to address problems and seize business opportunities.
• Excellent interpersonal skills, capable of establishing and maintaining effective relationships with individuals at all levels within and outside of CenCal. Skilled in team building and consensus development.
• Exceptional oral and written communication skills, with the ability to communicate clearly, persuasively, and professionally with diverse individuals and groups both internally and externally.
• Strong presentation skills, including the ability to tailor content for specific audiences and engage large groups effectively.
• Demonstrated ability to align with and promote organizational values, integrating them into management practices and encouraging staff to do the same.
• Strong customer service orientation.
• Excellent project management skills.
• Proficient in Microsoft Word and Excel.
• Ability to supervise staff effectively and ensure that direct reports manage their teams in a way that maximizes employee performance and business outcomes.
• Proficient in spoken and written English.
• Ability to handle confidential information with discretion and integrity.

Education & Experience

• Required:

• MD/DO degree from an accredited medical school.
• Successful completion of a residency program accredited by the American Council of Graduate Medical Education (ACGME) or the American Osteopathic Association (AOA).
• A minimum of three to five (3-5) years of clinical experience in the practice of medicine.
• At least 3-5 years of experience in Medi-Cal and Medicare Utilization Management/Case Management within a health plan, IPA, or similar medical management organization is preferred.
• Unrestricted license to practice medicine in California, issued by the State Board of Medical Examiners, and meeting the Health Plan’s credentialing and re-credentialing requirements.
• Board certification is required. – Prefer Internal Medicine or Family Practice.
• Valid California driver’s license with a clean driving record and reliable transportation, or the ability to obtain transportation as needed within the counties served by CenCal, if a medically documented disability prohibits obtaining a driver’s license.

Salary : $135 - $216