Apply on line at http://www.alohacare.org/Careers/Default.aspx

The Company:

AlohaCare is a local, non-profit health plan serving the Medicaid and Medicare dual eligible population. We provide comprehensive managed care to qualifying health plan members through well-established partnerships with quality health care providers and community-governed health centers. Our mission is to serve individuals and communities in the true spirit of aloha by ensuring and advocating access to quality health care for all. This is accomplished with emphasis on prevention and primary care through community health centers that founded us and continue to guide us as well as with others that share our commitment. As Hawaii’s third-largest health plan, AlohaCare offers comprehensive prevention, primary and specialty care coverage in order to successfully build a healthy Hawaii.

The Culture:

AlohaCare employees share a passion for helping Hawaii’s most underserved communities. This passion for helping and caring for others is internalized and applied to our employees through a supportive and positive work environment, healthy work/life balance, continuous communication and a generous benefits package.

AlohaCare’s leadership empowers and engages its employees through frequent diversity, recognition, community, and educational events and programs. AlohaCare has a strong commitment to support Hawaii’s families and reinforces a healthy work/home balance for its employees. Because AlohaCare values honesty, respect and trust with both our internal and external customers, we encourage open door, two-way communication through daily interactions, employee events and quarterly all-staff meetings. AlohaCare’s comprehensive benefits package includes low cost medical, dental, drug and vision insurance, PTO program, 401k employer contribution, referral bonus and pretax transportation and parking program.

These employee-focused efforts contribute to a friendly, team-oriented culture, which is positively reflected into the communities we serve.

The Opportunity:

The Medical Director of Population Health (“Medical Director”) is a key operational and strategic leader who assists the Chief Medical Officer (CMO) in providing medical direction to and support of several priority areas, including but not limited to, Long Term Services and Supports (LTSS); Dual eligible-Special Needs Plan (DSNP); and Population Health. LTSS involves Health Coordination and Home & Community Based Services. D-SNP includes Star Ratings and Model of Care. Population Health encompasses strategies to address Complex Care Management, Disease Management, GRACE (Geriatric Resources for Assessment and Care of Elders) program, and other programs of health outcomes for subpopulations of members. The success of the Medical Director depends largely on their ability to collaborate with the leaders and their teams across the Health Services Division and departments such as Quality, Provider Relations, and External Affairs. The Medical Director supports Behavioral Health, Health Equity, and Diversity-Equity-Inclusion and develops and implements strategies to address social determinants of health, including housing, nutrition, transportation, and education. The Medical Director gives guidance on clinical technology to improve the quality and safety of members in their homes and communities. The Medical Director utilizes advanced data analytics, including predictive modeling and artificial intelligence, to identify at risk populations, track health outcomes, and tailor interventions for improved effectiveness and efficiency.

The Medical Director participates in activities such as prior authorization, appeals and grievances, committee work, Inter-Disciplinary Team conferencing, community events, and coverage of medical colleagues. The Medical Director is mindful of the organization’s strategic goals, partnership with providers, engagement of members, closing gaps in care, and Medical Loss Ratio. The Medical Director complies with NCQA Accreditation standards, the QUEST Integration (Medicaid) Contract, and CMS rules and regulations.

Primary Duties and Responsibilities:

• Meet, communicate and coordinate regularly, and as necessary, with key operational and strategic leaders of Health Coordination, D-SNP, and Population Health;
• Support Community Health Workers, Care Navigators, Health Coordinators, Pharmacists, Pharmacy Technicians, and other member-facing staff;
• Join field staff on home visits to understand their challenges and, where appropriate, to give feedback in developing skills for member engagement, training curricula, and programs;
• Focus on closing gaps in care and improving performance results involving, HEDIS, Medicaid auto-assignment, Pay-For-Performance, and Star Rating measures;
• Understand and apply Key Performance Indicators, advanced analytics, predictive modeling, artificial intelligence to track health outcomes and tailor interventions for the identified high-risk or at-risk members;
• Collaborate with the D-SNP leaders and their teams in striving toward membership growth, reducing avoidable hospitalization, and attaining higher Star Ratings;
• Grow the number of members enrolled in the GRACE program, strengthen the relationship with their primary care team, close gaps in care, participate in the weekly IDTs, reduce acute hospitalization and avoidable emergency visits, and increase member and provider satisfaction;
• Help build partnership with community health centers, foster homes, skilled nursing facilities, hospices, private providers from independent clinicians to hospitals, collaborating with Provider Relations and Health Services departments;
• Support the Director and the Manager of Behavioral Health Programs in integrating medical and behavioral health and increasing BH provider network related to LTSS/HCBS, D-SNP, GRACE program;
• Assist the Population Health Officer and Director of Population Health in their strategic goals related to complex chronic care, disease management, health disparities, and advancing programs to support members getting healthier;
• Collaborate with the Director of Pharmacy and team in reducing polypharmacy, safety risks, non-adherence, and avoidable drug costs among members with chronic conditions, as well as supporting quality-of-care initiatives;
• Serve as a Subject Matter Expert and resource for geriatric medicine and care and act as a liaison with the geriatric community of providers;
• Attend community events that promote the value of AlohaCare as a community-based health plan among members, providers, and community influencers;
• Provide timely feedback to the External Affairs department, regarding legislative bills, policies from State agencies like DHS and DOH, regulations from CMS, and policy positions by advocacy health plan organizations (e.g., ACAP, MHPA, AHIP);
• Attend regular leadership meetings of the Health Services Division, Skip meetings with CEO, 1:1 meetings with the CMO, and others as directed;
• Participate upon assignment in standing committees that are comprised of providers from the community, including the Practitioners Advisory Committee (PAC), Credentialing Committee (CC), and/or Pharmacy & Therapeutics (P&T) Committee and Drug Utilization Review (DUR) Board;
• Develop and submit grants, upon direction, to advance strategic goals, projects, and programs aimed at member engagement and provider partnerships;
• Maintain financial literacy and be mindful of the Medical Loss Ratio and reducing avoidable, low-value utilization of medical expenses especially among D-SNP enrollees and high-risk Medicaid members;
• Be mindful of lifting the total administrative burden on providers.

Utilization Management

• Share in coverage determination and appeals related to ambulatory, DME, hospital, institutional, pharmacy, out-of-state, travel, and other benefit services;
• Conduct peer-to-peer discussions related to prior authorizations and levels-of-care;
• Review or evaluate medical policies related to LTSS, HCBS, SDOH, and health equity;
• Promote direct access to medical prior authorization policies by providers and members;

Other Responsibilities

• May be assigned membership in the Corporate Quality Improvement Committee (CQIC), Prior Authorization Review Committee (PARC)), Quality Steering Committee, ad hoc work groups, and/or other standing committees.
• Support and participate in strategic planning related to a program, department, division, or company, as requested;
• Participate in the Health Services Division business meetings;
• Cooperate with project managers and coordinators, fulfilling a specific prescribed role;
• Support efforts to integrate behavioral and physical health;
• Consider significant budgetary variances, Medical Loss Ratio, and cost-drivers like hospitalization and medication in decision-making;
• Contribute toward full regulatory or contractual compliance;
• Participate in working groups of MedQUEST, Department of Health, or other community organizations, as assigned;
• Is active in teaching or training staff and, upon approval, students or professional trainees;
• Attend community, State-wide, or national conferences that have been prior approved and budgeted;
• Take part in scheduled physician coverage, including weekends, holidays, Paid-Time-Off days, travel, conferences;

• Responsible to maintain AlohaCare’s confidential information in accordance with AlohaCare policies, and state and federal laws, rules and regulations regarding confidentiality. Employees have access to AlohaCare data based on the data classification assigned to this job title.

Requirements:

• Doctor of Medicine or Osteopathy(MD/DO)
• Resident of Hawaii
• Five or more years of quality work in a health system, hospital, clinic, physician group, or health plan
• Five or more years of clinical practice in direct patient care
• Experience in medical leadership of clinical services, programs, or provider organizations
• Experience in multi-disciplinary collaboration and team work
• Public speaking and professional presentation skills
• Analytic skills and skill at using data systems
• Proficient in Microsoft professional suite (Word, Excel, PowerPoint)

Preferred Requirement:

• Practiced in a community health center or rural clinic;
• Previous experience as a Medical Director or Chief Medical Officer
• Experience in a managed care organization or health plan
• Advanced degree such as Master of Public Health, Master of Healthcare Administration, or Master of Business Administration.
• Can continue to provide direct patient care up to half day per week as approved

Licensure/Certification:

• State of Hawaii unrestricted active license to practice medicine
• Board Certification

Mental, Physical and Environmental Demands:

• Sedentary Work: Exerting up to 20 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time but may involve walking or standing for brief periods.
• Inside working conditions
• No environmental hazards
• Requires operation of general office equipment to include PC

AlohaCare is committed to providing equal employment opportunity to all applicants in accordance with sound practices and federal and state laws. Our policy prohibits discrimination and harassment because of race, color, religion, sex (including gender identity or expression), pregnancy, age, national origin, ancestry, marital status, arrest and court record, disability, genetic information, sexual orientation, domestic or sexual violence victim status, credit history, citizenship status, military/veterans status, or other characteristics protected under applicable state and federal laws, regulations, and/or executive orders.