PacificSource Health Plans Associate Medical Director, Medicaid in Portland, Oregon
*THIS IS A PART TIME POSITION, .35 FTE *
Position Overview:Actively engage with the provider community in the Coordinated Care Organization region in support of the strategic and operational goals of PacificSource’s and the region’s Health Council. Provide clinical expertise for physical, behavioral, and oral health utilization management, as well as health promotion, disease management, pharmacy review, dental case review, grievance and appeals, quality programs, and cost of care management. Manage and coordinate externally-facing operations of appropriate departments and interface with appropriate regulatory agencies to influence, understand, and implement policies and procedures.Work in collaboration with regionally-based PacificSource staff as well as regional physicians and health care leaders to meet or exceed quality standards and to coordinate and facilitate work across lines of business and organizations in order to optimize operational and community effectiveness.
Lead the cross-organizational (Health Council, PacificSource, and local community) clinical work using process improvement techniques to analyze, identify, and implement changes to workflow, staff, and organizational structure that improve operational efficiency and effectiveness.
Attend and participate in all relevant local and PacificSource Care Management, Cost Management, Clinical, Quality, Utilization Management Committees and activities, including the Clinical Advisory Panel. Prepare / participate in agendas, collaborate with the committees, research topics presented to the committee, and follow through on committee decisions and tasks.
Actively participate as a key team member in relevant Manager/Supervisor meetings including meetings related to Population health, Provider Network, Quality, Risk, and Health Services Teams, as convened by Chief Medical Officer (CMO).
Be the chief liaison between the local provider community and PacificSource clinical enterprises to facilitate coordination and the execution of work.
As appropriate, review and manage appeals, and lend expertise to the preparation of cases for further external review, including OHA hearings.
As appropriate, provide expertise and medical interpretation with respect to claims adjudication, contract language, disputes and appeals, policy drafts, and care management issues.
As appropriate, oversee the management of appropriate care and case management related to acute, catastrophic, and long term cases.
As appropriate, participate as a subject matter expert in Cost of Care working groups, to include anticipation of trends impacting global budget, and proactively addressing those trends in line with Triple Aim goals.
As appropriate, review pre-authorizations, claims, and other cases involving pre- or post-service requests for coverage.
As appropriate, conduct other utilization review activities (e.g. lengths of stay, appropriateness of service, intensity of service, medical necessity, and experimental/investigational services) on a prospective, concurrent, or retrospective basis.
As assigned, assist with credentialing review of providers and the resolution of issues brought forward by credentialing staff. Help to staff the Credentialing Committee, prepare agendas, present practitioner issues, develop policies, and oversee actions of the committee.
As assigned, assist with Pharmacy and Therapeutics Committee functions, as defined by Pharmacy Director.
Assist the Chief Medical Officer, as requested, including periodic involvement with providers, and members, PacificSource management, board, and other functions or committees as needed.
Collaborate with PacificSource and local providers and 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.
As assigned, research new technologies, new medications, and other evolving healthcare products and services to help determine a standard of care and standard of coverage. Assist with drafting and revision of policies relating to such issues.
Provide visibility and maintain positive physician relationships as a representative of PacificSource, in local and regional medical community.
As assigned, be specifically 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.
Provide clinical expertise to the Quality / Risk Department, including QIMs, NCQA, HEDIS, and CAHPS Programs.
As appropriate, develop annual department budgets. Monitor spending versus the planned budget throughout the year and take corrective action where needed.
Responsible for process improvement and working with other departments to improve interdepartmental processes. Utilize visual boards and daily huddles to monitor key performance indicators and identify improvement opportunities.
Meet department and company performance and attendance expectations.
Perform other duties as assigned.
Work Experience:MD or DO required. Three to five years as an Assistant Medical Director or Medical Officer of a health insurance plan or equivalent work experience strongly preferred.Experience in an integrated healthcare system a plus. Significant senior management policy and decision-making experience, including developing and implementing management best practices preferred.
Education, Certificates, Licenses:Unrestricted license to practice medicine by the Oregon State Board of Medicine. Board certification recognized by American Board of Medical Specialties (ABMS).
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. These include, but are not limited to quality improvement including, Lean methodology, healthcare economics, personnel administration, financial and cost analysis, trends in the healthcare industry. Excellent understanding of all areas of medical conditions, treatment, and care. Excellent understanding of the insurance industry and risk factors and how they relate to the PacificSource organization. Remain current in the medical field. Basic computer skills required. In-depth knowledge of local clinical communities, along with in-depth knowledge of Oregon Health Plan preferred. Ability to read and comprehend Spanish a plus.
Building Organizational Talent
Coaching and Developing Others
Operational Decision Making
Passion for Results
We are committed to doing the right thing.
We are one team working toward a common goal.
We are each responsible for our customers’ experience.
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-internal and external.
We encourage creativity, innovation, continuous improvement, and the pursuit of excellence.
Environment:Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 30% of the time.
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.
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.
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.
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.