PRIMARY FUNCTION: The Senior Medical Director of Medical Management is responsible for the leadership of medical management activities. Under the direction of the Chief Medical Officer (CMO), the Senior Medical Director of Medical Management has primary responsibility for both operational and clinical excellence across utilization management, disease management, and case management functions in our unique, at-risk private pediatric medical home model. As such, the role includes:
- Working directly with the Chief Medical Officer to design and implement medical quality programs/policies, evaluate opportunities for improvement, and coordinate/collaborate with the Pediatric Associates clinicians to execute on the opportunity
- Establishing case management, utilization review, quality and outcome management, and other education programs to provide high quality, cost effective health care services.
- Maintaining and cultivating relationships with our pediatric clinicians, specialty clinicians, facility partners, and health plan medical directors & clinical teams.
- Supporting the executive team and clinical staff in strategic planning, compliance, and process improvement in order to deliver efficient, high quality, affordable care to all Pediatric Associates’ patients.
- Having a strong understanding of how to leverage data and clinical know-how in a fast-paced care delivery setting
REPORTS TO: Reports directly to the Chief Medical Officer
ESSENTIAL FUNCTIONS OF THE JOB: (This list may not include all of the duties that may be assigned.)
- Primary responsible physician for fulfilling in house case review requirements, which includes review of cases sent for Second Level Review
- Primary responsible physician for leading utilization management and case management efforts. This includes conducting reviews with Case Managers and Utilization Managers, leading Peer to Peer reviews, establishing internal review guidelines, and implementing/using nationally recognized guidelines (i.e. InterQual, Milliman).
- Identify trends, as well as anomalies, by working with the analytics team to research errors, unauthorized or non-covered services, or out of network care in order to improve accuracy in delivery of covered services, reduce over utilization, costs and improve outcomes
- Responsible for operational oversight and excellence of utilization management, alongside all clinical executives. Key to role is also the ability to help develop and work metrics/dashboards to track performance (clinical and financial outcomes) and leverage in discussions with health plan
- He/she will develop a deep clinical understanding of the company model and play an important role interacting with plan medical director(s)/CMO’s and primary care providers.
- He/she must have the ability to make strong clinical and quality arguments to health plans and clinicians in order to improve performance.
TYPICAL WORKING CONDITIONS: Working in a professional office environment. The position involves high & frequent call volumes. Environment requires ability to multi-task, communicate clearly & concise, data entry for extended period of times. Will require sitting for long periods of time.
- Active Florida medical license and good standing with the Florida Board of Medicine
- Minimum 3-5 years’ experience in direct pediatric clinical practice
- Minimum 5-years’ experience in a leadership role for UM/QI or equivalent in a complex healthcare delivery system
- Knowledge and experience with home-based services, SNF, or broader post-acute care needed
- Knowledge and experience with Peer to Peer, chronic care program management, population health, and quality/HEDIS programming needed
- Needs working knowledge of statistical analysis, clinical epidemiology, and medical informatics; as well as experience working in medical management of Medicaid products
- Diplomatic & collaborative interpersonal communication, listening and presentation skills
- Experience working Experience working both independently and in a team environment in a dynamic, fast-paced environment
- Adhere to all organizational information security policies and protect all sensitive information including but not limited to ePHI and PHI in accordance with organizational policy, Federal, State, and local regulations.
- Current unrestricted Florida medical license as a Doctor of Medicine or Doctor of Osteopathic Medicine
- Pediatric Board Certified - American Board of Medical Specialties
- Active FL License or ability to obtain FL license
*Upon hire, and for the duration of the employment period driver’s license must be active and valid.*
Knowledge, Skills & Abilities:
- Customer focus - Builds strong customer relationships and delivers customer-centric solutions
- Demonstrates self-awareness - Uses a combination of feedback and reflection to gain productive insight into personal strengths and weaknesses
- Ensures accountability - Holds self and others accountable to meet commitments
- Drives results - Consistently achieves results, even under tough circumstances
- Develops talent - Develops people to meet both their career goals and the organization’s goals
- Drives engagement - Creates a climate where people are motivated to do their best to help the organization achieve its objectives
- Interpersonal savvy - Relating openly and comfortably with diverse groups of people
Technical knowledge and skills
- Excellent clinical skills
- Knowledge and experience in a managed care delivery system
- Knowledge of clinical outcomes and quality improvement processes
- Experience with population risk management or complex chronic disease care management
- History of being a natural teacher to fellow clinicians
Other skills and abilities
- A mission-driven individual who can embrace and commit to Mission and Core Values
- A self-starter, results-oriented personality with an interactive style which is pleasant
- High tolerance for complex, ambiguous, and ever-shifting environments
- A philosophy of collaboration and teamwork with a demonstrable track record in forging physician/management relations
- Conflict management and resolution skills
- Good analytical skills
- Proficient in Microsoft Office Suite products, including Excel, Word, PowerPoint and Outlook
- Computer skills: Comfortable with the electronic medical record (EMR) & keyboarding
Adhere to all organizational information security policies and protect all sensitive information including but not limited to ePHI and PHI in accordance with organizational policy, Federal, State, and local regulations.
- Excellent interpersonal skills, with the ability to build consensus and forge strong clinician/management relationships