July 16, 2019
Would you thrive in a highly regarded, mission driven organization that is dedicated to ensuring quality, cost effective care for the underserved? Does your background include experience in Medical Management such as Utilization and Care Management or Quality in Managed Care or Managed Medi-Cal settings? Do you possess exceptional organization and communication skills? Does the opportunity to work collaboratively with a senior management team that strives for excellence appeal to you? If so, CenCal Health has an exciting opportunity that you may want to consider!
CenCal Health (formerly The Santa Barbara Regional Health Authority) is the Medi-Cal Managed Care Program for low income residents of Santa Barbara and San Luis Obispo counties. Since its inception in 1983, CenCal Health has, among other things, created access to high quality health care for its members through contracts with local providers and through a primary care provider case management network in addition to Health Education and Disease Management programs and activities. The program that began at CenCal is now acknowledged to be the oldest Medicaid managed care program of its kind in the country and has since become a demonstration program for other counties and states which is a model for Medicaid reform.
CenCal Health is dedicated to the community and local residents. Medi-Cal is CenCal Health’s largest program that is currently serving approximately 178,000 residents in their service areas of Santa Barbara and San Luis Obispo counties. Once members are in the CenCal Health system, they are able to choose (or have assigned) a Primary Care Physician (PCP), which will serve as their “medical home”. Cen Cal Health’s mission is to improve the health and well-being of the communities they serve by providing access to high quality health services, along with member education and outreach. There is a dedicated bi-lingual, bi-cultural Member Services Department that is able to assist with member questions, appointment scheduling, arranging non-emergency transportation if required, interpreter services at provider offices when needed at no cost and numerous other services.
Santa Barbara is a 2-hour drive north from Los Angeles or a short hop from any corner of the world via the Santa Barbara airport. The city lies between the sleepy Santa Ynez Valley and the Pacific Ocean with a population of 88,410, making it the second largest city in the county after Santa Maria, while the contiguous urban area, which includes the cities of Goleta and Carpinteria, along with the unincorporated regions, have a population of 220,000. The city economy includes a large service sector, education, technology, health care, finance, agriculture, manufacturing and local government. Education in particular is well represented with five institutions of high learning on the south coast. Behind the city is the Los Padres National Forest, which contains several remote wilderness areas. Santa Barbara’s harbor is home to the world-famous Stern’s Wharf and visiting the Wharf and the zoological gardens makes a scenic and educational day trip. From the city, you are just minutes away from the world-famous Santa Barbara wine country. The gorgeous Santa Ynez Valley, with its breath-taking vistas is home to such notable attractions as Solvang and the Chumash Reservation. Santa Barbara’s climate is often described as Mediterranean and it is sometimes referred to as the American Riviera. Its beautiful beaches, majestic mountains, and colorful culture make Santa Barbara a premier place to live and work. Please visit the Santa Barbara Conference & Visitor Council’s website at http://www.santabarbaraca.com for more information.
Reporting to the Chief Medical Officer, or his/her designee, the Medical Director is responsible for providing clinical oversight for utilization, quality, care management and credentialing functions in a manner that ensures the delivery of quality, cost effective healthcare, supports organization objectives, and meets contractual and regulatory requirements. Work is varied and highly complex, and requires a moderate high degree of discretion and independent judgment. This position will focus on CenCal Health’s adult members and their service needs.
DUTIES AND RESPONSIBILITIES
- Provides clinical leadership for Medical Management functions; assists subordinate managers in resolving Medical Claims Review, Grievances, Appeals, and other Medical Management issues.
- Works closely with the CMO and other Medical Directors to identify medical service issues that have an impact on plan benefits and their administration, develop action plans and monitor results
- Identifies, analyzes, and assists in identifying quality issues and trends; makes recommendations based on findings; develops and implements agreed upon changes.
- Provides clinical expertise needed to effectively and efficiently resolve complex, controversial and/or unique administrative circumstances. This includes working with internal and external groups.
- Conducts clinical reviews and makes UM decisions for prior, concurrent (hospital/ skilled nursing facility) and retro authorizations, and appeals; approves/denies or offers medical alternatives according to CenCal Health medical review criteria; willingness to outreach to providers by phone and in person as needed; develops UM policies and procedures in coordination with Health Services staff.
- Works collaboratively with the Pharmacy team on clinical appropriateness of medication utilization.
- Establishes and maintains working relationships with providers, provider organizations and other stakeholders that support contracting, provider relations, marketing and other organizational goals and objectives.
- Dedicated to process improvement and organizational efficiencies.
- Clinical oversight and development of care management strategies and opportunities.
- May support population health activities.
- No current direct reports, the position may supervise other Health Services staff in the future.
- May participate in committee assignments such as Credentialing, Peer Review, Pharmacy & Therapeutics, and/or Quality Improvement.
- Other duties as assigned.
REQUIRED SKILLS, KNOWLEDGE & ABILITIES
- In-depth knowledge of the principles and practices of Managed Care related to Utilization Management, Case Management and Discharge Planning.
- In-depth knowledge of the healthcare, economic or other issues affecting Medi-Cal and/or Medicare populations, providers and the underserved preferably in Santa Barbara and San Luis Obispo Counties and surrounding areas.
- Basic knowledge of managed healthcare as applied to government sponsored programs including Medicaid.
- Strong knowledge of and ability to identify, implement, monitor and analyze relevant metrics models, and implement effective interventions based on results.
- In-depth knowledge of standard contract components and contract language specific to healthcare.
- In-depth knowledge of audit, control and monitoring processes, and the ability to effectively implement and maintain them.
- Understanding of population health concepts and social determinants of health.
- Very strong facilitation, problem solving and conflict resolution skills.
- Ability to create, execute and monitor relevant strategic and business plans.
- Strong collaboration skills with demonstrated ability to create and foster a collaborative, team based, work environment, maintain effective, high performance teams, and organize people and resources to solve problems and identify business opportunities.
- Very strong interpersonal skills, with the ability to establish and maintain effective working relationships with individuals at all levels inside and outside of CenCal.
- Effective at building teams and consensus.
- Very strong oral and written communication skills, with the ability to communicate professionally, effectively and persuasively to diverse individuals and groups inside and outside of CenCal.
- Strong presentation skills, including the ability to tailor presentations to a specific audience, and address and interact with large groups.
- Demonstrated ability to articulate and embrace organizational values, integrate into management practices, and foster their manifestation among staff.
- Strong customer service skills.
- Strong project management skills.
- Intermediate skills in Word and Excel.
- Ability to supervise staff, and ensure that direct reports supervise staff, in a manner that maximizes employee performance and business results.
- Ability to speak and be understood in English.
- Ability to handle confidential information with appropriate discretion.
Management Administration Skills: Manages and/or facilitates employees, budgets and equipment assigned to them, while helping employees maintain a clear picture of their roles and responsibilities to achieve organizational objectives. Helps to develop employee performance by delegating responsibilities and providing accurate feedback and assessments on a timely basis.
Leadership Skills: Able to assume a role of formal or informal authority as necessary; advocate new ideas, even when risk is involved; delegate responsibility and empower associates to make decisions; capable of providing constructive feedback to others; able to receive constructive feedback from others; makes personal commitment to mentor and grow others.
Strategic Thinking: Formulates objectives and priorities and implements plans consistent with the long-term interest of the organization in a global environment, Capitalizes on opportunities and manages risks.
Communication Skills-Oral, Listening & Written: Communicates both verbally & in writing in such a manner that it is easy to understand and interpret what and why information is being communicated. Listens attentively without interrupting and/or being distracted by other things.
Collaboration & Teamwork: Utilizes communication techniques & methods that generate trust, collaboration, open two-way communication and a supportive work environment. Develops and generates team momentum, enthusiasm, and camaraderie to obtain maximum team performance. Values diverse talents of team members and works to include various points of view in decision-making.
Human Capital Management: Builds and manages workforce based on organizational goals, budget considerations, and staffing needs. Ensures employees are appropriately recruited, selected, appraised, and rewarded; takes action to address performance problems. Manages a multi-sector workforce and a variety of work situations.
Conflict Management: Encourages creative tension and differences of opinions. Anticipates and takes steps to prevent counter-productive confrontations. Manages and resolves conflicts and disagreements in a constructive manner.
Decisiveness: The ability to make difficult decisions in a timely manner.
Walk the Talk: Do what you say you are going to do. Be accountable for your actions.
World Class Mindset: Behaves in an honest, fair, and ethical manner. Shows consistency in words and actions. Models high standards of ethics. Punctual, exhibits professional email etiquette. Adhere to company and department standards. Commitment to excellence.
EDUCATION AND EXPERIENCE
- MD degree from an accredited medical school
- Satisfactory completion of an American Council of Graduate Medical Education accredited residency program; family medicine or internal medicine preferred.
- At least five (5) years clinical experience in the practice of medicine in fields related to a Managed Care setting.
- Equivalent combination of experience.
- Experience in Utilization Management/Case Management in a clinical setting.
- Unrestricted license to practice medicine in the State of California, issued by the State Board of Medical Examiners, which meets the Health Plan’s credentialing and re-credentialing requirements.
- Board eligibility in a chosen specialty; Board Certification preferred
- Valid California driver license with a clean driving record and reliable transportation or, the ability to obtain transportation on demand in the counties served by CenCal if prohibited from getting a driver license due to a medically documented disability.
- Physical requirements needed to perform the essential functions of this job, with or without accommodation:
o Mobility Requirements: ability to operate a keyboard and sit for long periods; stand, sit, reach, bend, crawl, stoop, lift up to 10 lbs.
o Visual Requirements: ability to read close-up and do close-up work.
o Dexterity Requirements: ability to perform repetitive motion (keyboard); writing (note-taking)
o Hearing/Talking Requirements: ability to hear normal speech, hear and talk on the telephone
o Emotional/Psychological Requirements: ability to deal with public contact, in person and normal office environment. Must be able to sit and work at a computer for long periods of time
- Must be able to travel outside the office and attend meetings during and after regular work hours
- Regular attendance is essential to perform this job.
The Medical Director will have an opportunity to make a significant contribution to the lives of CenCal’s member population. Share your vision, expertise and skills with a company that is committed to improving the quality and cost of healthcare for the underserved!
For further information, please contact:
Mary Niccum or Susan Pisarik
The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform. The Alliance reserves the right to revise this job description at any time.
The Alliance is an equal employment opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender perception or identity, national origin, age, marital status, protected veteran status, or disability status.
Applicants must be currently authorized to work in the United States on a full-time basis.