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Medical Director, Health Plan Products - Limited Term

Job ID SHP-1901345 Date Posted 01/23/2019 Location Sacramento, California
Position Overview:

As the Medical Director, Health Plan Products you will oversee commercial products which include Sutter Health Plan HMO and Partnered Employer Products. This includes medical and pharmacy appeals, grievances, out of area concurrent review, post-stabilization determinations and continuity of care requests. You will be responsible for identifying potential quality incidents and will make appropriate assessments and referrals to Peer Review as required. Additionally, you will be accountable to:

  • Oversee short term case management as conducted by RN staff
  • Manages and direct resolution of escalated issues that arise outside of  normal UM and appeal channels
  • Provide support and assistance to Provider Relations, Vendor Management, Communications, Quality, Wellness, Member Services and Delegation Oversight staff
  • Represents Sutter Health Plan and Partnered Employer Products with internal and external stakeholders regarding utilization analysis, quality metrics and wellness activities
  • Ensure compliance with all regulations and will operate in accordance with the National Committee on Quality Assurance (NCQA) standards
  • Be an active participant in Sutter Medical Network UM and QM activities
  • Support the CMO with planning and implementation for health plan products
  • Provide clinical consultation to SutterSelect, plan administrator for the ERISA self-insured health plans sponsored by Sutter Health and its affiliates
  • Develop, oversee and monitor clinical quality and utilization management programs for SutterSelect, serving as a physician advisor to SutterSelect leadership for medical policy, new product development, clinical program design and benefit changes to improve service and plan performance

Our ideal candidate will be the ultimate relationship builder with exceptional leadership, interpersonal, organizational and problem-solving skills. You should be an exceptional communicator and be comfortable delivering presentations on clinical outcomes to various audiences. Simplifying complex, technical, regulatory and contractual information should come with ease along with the ability to garner confidence from health plan leadership, affiliates vendors and consulting staff.

  • Doctor of Medicine (MD), Doctor of Osteopathic Medicine (DO) or equivalent education/experience
  • Current, unrestricted CA medical license
  • 5 or more years of clinical practice experience
  • Comprehensive understanding of managed care operations in general, including healthcare operations/structure and a general understanding of the interactions and interdependencies of an integrated delivery system
  • 2 or more years of experience as a Medical Director for a health plan or medical group
  • Experience interpreting clinical data within the specific case context

Preferred Qualifications

  • Experience with health insurance trends, technology and statistics in a healthcare setting
  • Experience with HMO product-lines and applicable regulatory requirements (DMHC)
  • Experience with PPO and self-funded product-lines and regulatory requirements
  • Familiarity with Northern California and the Sutter Footprint (preferred practice and managed care experience within the Northern California market)

Organization: Sutter Health Plan
Employee Status: Limited Term
Benefits: Yes
Position Status: Exempt
Union: No
Job Shift: Day
Shift Hours: 4 Hour Shift
Days of the Week Scheduled: Monday-Friday
Weekend Requirements: Other
Schedule: Part Time
Hrs Per 2wk Pay Period: 40

All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, marital status, sexual orientation, registered domestic partner status, sex, gender, gender identity, or expression, ancestry, national origin, age, medical condition, physical or mental disability, military or protected veteran status, political affiliation, pregnancy, childbirth or related medical condition, genetic information or any other characteristic made unlawful by local, state, or federal law, ordinance or regulation. External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state, and local laws, including but not limited to the San Francisco Fair Chance Ordinance.

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