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PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.
Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.
The Senior Medical Director is responsible for leading improvement in clinical development strategies, and execution of clinical programs including implementation of the strategic plan through strategic cascades and metrics, and the oversight of operational activities of the medical directors. This role leads a clinical team with assigned medical directors and reports to the Chief Medical Officer (CMO). The Senior Medical Director role interfaces and collaborates with health services project management and leadership within PacificSource to carry out the initiatives of the strategic plan and CMO. The Senior Medical Director may interface with appropriate governmental and regulatory agencies to influence, understand, and implement policy. The Senior Medical Director is expected to actively engage with the provider community in support of PacificSource's strategic and operational goals. The Senior Medical Director is a community leader with all Health Services VPs and the CMO.
Essential Responsibilities:
Lead clinical utilization review efforts (e.g. lengths of stay, appropriateness of service, intensity of service, medical necessity, and experimental/investigational services) on a prospective, concurrent, or retrospective basis coordinating with the medical director and utilization management operational team.
Oversee pre-authorizations review, claims, and other cases involving pre- or post-service requests for coverage.
Provide expertise and medical interpretation with respect to claims adjudication, underwriting, contract language, disputes and appeals, policy drafts, and care management issues.
Lead the efforts of Medical Directors to establish guidelines, policies, criteria and procedures for review and determination related to clinical practices, claims, care coordination, reimbursement, provider credentialing, and quality management.
Oversee the development of systems of care with providers for management of appropriate care and case management related to acute, catastrophic, and long-term cases.
Provide clinical and operational expertise for physical and behavioral health care, quality, case management, risk, network, and utilization management, as well as health promotion, disease management, pharmacy review, grievance and appeals, quality incentive programs, and revenue cycle management.
Lead Cost Containment Committees, work to include anticipation of trends impacting global budget, and proactively address those trends in line with Triple Aim goals.
Manage internal operations and participates in activities related to the cost of care and cost and use functions with certain defined Provider Partners and in Coordinated Care Organization (CCO) Special Operations Committees.
Within the clinical care domain, manage all aspects of data and analytics to deliver actionable analytics to provider partners, with aim to achieve lower cost care with better quality and greater customer satisfaction.
Provide leadership in decision making for inclusion and integration or continuation of new clinical services within Health Services.
Lead the work of applying process improvement techniques to analyze, identify, and implement changes to workflow, staff, and organizational structure that improve operational efficiency and effectiveness in the areas of authority of the Senior Medical Director.
Work with the Chair Quality Assurance Utilization Management and Pharmacy and Therapeutics Committees as needed. Prepare agendas, collaborate with the committee, research topics presented to the committee, and follow through on committee actions.
Review and manage appeals and grievances. Lend expertise to the preparation of cases for appeals, presentation, or further external review. Assist in reviewing Pharmacy denials and redeterminations.
In collaboration with CMO and other Medical Directors interface with the Oregon Health Authority to influence, track, and implement Oregon Health Plan clinical policy; including active participation in relevant committee work e.g. Quality Health Outcome Committee.
Develop annual department budgets. Monitor spending versus the planned budget throughout the year and take corrective action where needed Responsible for hiring, staff development, coaching, performance reviews, corrective actions, and termination of employees. Provide feedback to direct reports including regular one-on-ones and performance evaluations.
Closely assist the Chief Medical Officer (CMO) with providers, clients, agents, PacificSource management, board, and other functions or committees.
Provide visibility and maintain positive physician relationships as a representative of PacificSource in local and regional medical community.
Actively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy.
Supporting Responsibilities:
Coordinate business activities by maintaining collaborative partnerships with key departments.
Meet department and company performance and attendance expectations.
Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
Perform other duties as assigned.
SUCCESS PROFILE
Work Experience: A minimum of five as an Assistant Medical Director or Medical Officer of a health insurance plan strongly preferred. Experience in an integrated healthcare system preferred. Extensive senior management policy and decision-making experience, including developing and implementing management best practices required. Extensive management experience with clinicians required. MBA, MHA, or MS in relevant fields preferred.
Education, Certificates, Licenses: MD or DO. Unrestricted license to practice medicine by the Oregon State Board of Medical Examiners. Doctor of Medicine degree required. Must be able to obtain license to practice in states where PacificSource operates.
Knowledge: Comprehensive knowledge of business principles and techniques of administration, organization, and management to include an in-depth understanding of the key business issues that exist in the healthcare industry. Knowledge of strategic and operational planning, healthcare economics, personnel administration, federal health reform laws, financial and cost analysis, trends in the healthcare industry, and delivery system transformation including medical home initiatives, business process improvements, analysis and redesign. Excellent verbal and written communication skills, ability to read, analyze and interpret documents, schedules, reports, budgets and correspondence. The ability to develop presentations and reports as well as effectively present information. Use and implementation of the following tools and concepts across all teams within scope of accountability: training, strategy deployment, standard work, visual management, daily improvement, standard follow-up and team development. Strong research, analytical, organizational, and interpretative skills. Excellent understanding of all areas of medical conditions, treatment, and care. Possesses the ability to foresee changes in treatment patterns and implement internal systems as needed. Understanding of the insurance industry and risk factors. The ability to identify, create, analyze, and implement innovative cost containment procedures. Excellent negotiating skills. Pro-active in the application of new medical systems and procedures. Expertise in quality assurance and utilization review. Basic computer skills preferred.
Competencies
Building Trust
Building a Successful Team
Aligning Performance for Success
Building Partnerships
Customer Focus
Continuous Improvement
Decision Making
Facilitating Change
Leveraging Diversity
Driving for Results
Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 25% of the time.
We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:
We are committed to doing the right thing.
We are one team working toward a common goal.
We are each responsible for customer service.
We practice open communication at all levels of the company to foster individual, team and company growth.
We actively participate in efforts to improve our many communities-internally and externally.
We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.
We encourage creativity, innovation, and the pursuit of excellence.
Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.
Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.
