Medical Director (Transplant and Complex Cancer Surgery Program)

Job Description

Medical Director (Transplant and Complex Cancer Surgery Program)

Job Description

Why CalOptima?
CalOptima is the single largest health plan in Orange County, serving 880,000 members, or one in four residents. Our motto "Better. Together. is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community's health. If you're looking for an opportunity to work for an organization dedicated to improving local health care and serving the needs of the most vulnerable, we encourage you to join CalOptima.

Job Summary

The CalOptima Medical Director (Transplant and Complex Cancer Surgery Program) is a key member of the medical management team and is responsible for leading the design, development and implementation of a Transplant and Complex Cancer Surgical oversight program. The incumbent will collaborate with other Medical Directors and clinical, nursing and non-clinical leadership staff across the organization in areas including Quality Management, Utilization and Care Management, Health Education/Disease Management, Long Term Support Services, Pharmacy Management, Behavioral Health Integration, Program for All Inclusive Care for the Elderly (PACE), as well as internal and external coordination including providers, community programs, Compliance, Information Technology Services, Claims Administration, Contracting and Provider Relations.

Position Responsibilities:

Cultivates and promotes a mission driven culture of high-quality performance, with a member focus on customer service, consistency, dignity, and accountability.
Directs and assists the team in carrying out department responsibilities and collaborates with the leadership team and staff to support short and long-term goals/priorities for the department.
Provides clinical support for all areas of medical affairs and strategic vision in support of transplant/complex cancer surgical program.
Develops core strategies and plans to build out the High Value Network for specialty Transplant and Cancer Surgical procedures that includes analysis of transplant/specialty surgical centers and individual surgeon performance and measurement.
Leads the organization's efforts in establishing evidence-based practice standards and clinical practice criteria specific to transplant and cancer surgical care within the CalOptima Health Networks. Establishes transplant selection criteria and multi-organ decisioning protocols for internal teams and external providers.
Develop key performance indicators and outcome metrics for transplant patients to establish baseline and longitudinal post-transplant care measurement
Strategizes, drives and monitors process improvements that focus on innovative care and/or improved patient care outcomes, safety and support of a patient-centered and healing environment.
Promotes a high level of collaboration within a highly matrixed team environment in order to coordinate activities, review work, exchange information, and resolve problems.
Champions, models and promotes service excellence philosophies and behaviors at the facility, provider and county levels to enhance overall patient experience for Transplant and Complex Cancer surgical care. Manages and oversees transplant and complex cancer medical review processes; reviews prior authorization requests and conducts retrospective reviews of claims and appeals.
Reviews and resolves specialty Transplant and Complex Cancer procedures grievances related to medical quality of care and actively participates in the functioning of the plan's grievance and appeals processes.
Ensures medical decisions are rendered by qualified medical personnel and are not influenced by fiscal or administrative management considerations.
Follows, implements and develops medical protocols, policies and rules of conduct for plan medical personnel as applicable.
Oversees the implementation of quality improvement activities including the identification and resolution of utilization management/quality management issues of network practitioners; recommends corrective action as needed.
Educates and communicates with network and group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management
Fosters Clinical Practice Guideline implementation and evidence-based medical practice.
Collaborates with other departments i.e. Member Services, Provider Services, Claims and Contracting, to coordinate operations and programs.
Utilizes assigned data analysts to produce tools used to report, monitor and improve utilization management.
Attends or chairs committees as directed by the Chief Medical Officer as well as participates in regulatory, professional and community activities to provide CalOptima input and become knowledgeable regarding regulatory, professional and community standards and issues.
Facilitates conformance to Department of Health Care Services (DHCS), Centers for Medicare and Medicaid Services (CMS), Department of Managed Health Care (DMHC), National Committee for Quality Assurance (NCQA) and other regulatory requirements.
Other projects and duties as assigned.

Possesses the Ability To:

Understand, communicate and implement regulations, policies and guidelines.
Establish and maintain successful interpersonal relationships with all levels of CalOptima leadership and staff, external stakeholders, agencies, and the public.
Communicate clearly and concisely, both verbally and in writing.
Work under the pressure of strict deadlines on multiple projects in a fast-paced environment.
Collaborate with and direct others, e.g. ensuring medical decisions are rendered by qualified medical personnel.
Utilize and access computer and appropriate software (e.g. Microsoft Office; Word, Excel, PowerPoint) and job-specific applications/systems.

Experience & Education:

Medical Doctorate degree from a fully accredited university required.
Current, valid, unrestricted California Physician & Surgeon's License with Board certification in area of specialty required.
5 years of active clinical practice experience required.
Experience in Utilization Management required.
Experience working with Medicare, Medi-Cal and MCG (Medicare Milliman Clinical Guidelines) required.

Knowledge of:

NCQA, Health Insurance Portability and Accountability Act (HIPAA), DHCS, DMHC or similar regulators.
Medicare and Medi-Cal benefits and regulations, as well as its population and demographics.
Evidence-based medical guidelines (nationally recognized standards of health care), utilization management, quality improvement and other medical management functions.
Principles and practices of healthcare, health care systems and medical administration.

Department(s): Medical Management
Reports to: Chief Medical Officer (CMO)
FLSA status: Exempt
Salary Grade: V - $266,000 - $437,800

CalOptima is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima wants to have qualified employees in every job position. CalOptima prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.

If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. You can request reasonable accommodations by contacting Human Resources Disability Management at 657-900-1134.

Job Location: Orange, California

Position Type:

To apply, visit https://apptrkr.com/3060570

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