Summary

Assist the Chief Care Officer to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit. Provides direct high quality patient care in their respective specialty to patients. Collaborates and works effectively with other providers and staff to provide effective team based medical care.

Essential Duties and Responsibilities:

• Demonstrates behaviors that are important to the success of the organization and that support and uphold ChapCare’s Mission, Vision and core values.

• Uses effective communication skills with patients and staff. Follows proper organizational communication lines to address matters pertaining to job functions including proper reporting relationships.

• Provides medical leadership of business unit for utilization management, cost containment, and medical quality improvement activities. Performs medical review activities pertaining to utilization review, quality assurance, medical review of complex patients, and medical services. Supports effective implementation of performance improvement initiatives.

• Assists Chief Care Officer in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members. Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, accreditation requirements and scope of practice.

• Assists the Chief Care Officer in the functioning of the physician committees including committee structure, processes, and membership. Oversees the activities of physicians and mid-levels assigned to business unit. Utilizes the services of medical, pharmacy, behavior health, patient education & wellness programs, consultants for reviewing complex cases and medical necessity appeals. Participates in provider network development and new market expansion as appropriate.

• Assists in the development and implementation of physician education with respect to clinical issues and policies. Collaborates with the Chief Care Officer and administrative staff to develop and implement medical protocols and quality initiatives within the practice

• Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components. Identifies clinical quality improvement programs to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care.

• Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality. Applies effective interpersonal skills, demonstrates professional skills in the knowledge of their specialty.

• Provides direct medical care and is able to work effectively to provide cost efficient and timely quality medical care to patients.

• Develops alliances with the provider community through the development and implementation of the medical management programs. As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues. Represents the business unit at appropriate local and state committees and other ad hoc committees

Qualifications:

• Active California medical license and good standing with the Medical Quality Control Board of the State of California.

• Minimum 5-years’ experience in a leadership position

• Demonstrable leadership role and achievement in a complex healthcare delivery system.

• Experience in fiscal accountability and budgeting.

• Knowledge and experience of quality infrastructure is needed, including how to develop and implement decision tools, clinical protocols and guidelines, care management programs, and outcome measurement assessments.

• Needs working knowledge of statistical analysis, clinical epidemiology, and medical informatics; understanding of best practices and how to successfully introduce information technology into clinical practice.