Sutter Health Medical Director, Health Plan Products in Sacramento, California
The Medical Director has day to day responsibilities for Commercial products, including SHP HMO and Partnered Employer Products (PEP). This includes medical and pharmacy appeals, grievances, out of area concurrent review, post-stabilization determinations, continuity of care requests. Identifies Potential Quality Incidents and makes appropriate assessment and referral to Peer Review as indicated. This role also has oversight of short term case management as conducted by RN staff. This physician manages and directs resolution of escalated issues that arise outside of normal UM and Appeal channels using the resources of the Clinical Department. Provides support and assistance to Provider Relations, Vendor Management, Communications, Quality, Wellness, Member Services and Delegation Oversight staff as needed. Represents SHP and PEP with internal and external stakeholders regarding utilization analysis, quality metrics and wellness activities. Ensures compliance with all regulations and operates in accordance with the National Committee on Quality Assurance (NCQA) standards. Active participant in SMN UM and QM activities. Supports CMO with planning and implementation for health plan products.
Provides clinical consultation to SutterSelect, plan administrator for the ERISA self-insured health plans sponsored by Sutter Health and its Affiliates. Responsible for the development, oversight and monitoring of clinical quality and utilization management programs for SutterSelect. Serves as physician advisor to SutterSelect leadership team for medical policy, new product development and clinical program design and benefit changes to improve service and plan performance.
Doctor of Medicine degree (MD) or the Doctor of Osteopathic Medicine degree (DO) Required Or equivalent education/experience
Current, Unrestricted California Medical License required.
•5+ years clinical practice required.
•Comprehensive understanding of managed care operations in general, including health care operations, structure, and general understanding of the interactions and inter-dependencies of an integrated delivery system Required
•2-5 years experience in health plan or Medical Group medical director role required.
•Experience with health insurance trends, technology, and statistics in the healthcare setting preferred.
•Experience with HMO product-line applicable regulatory requirements (DMHC) preferred.
•Experience with PPO and self-funded Product-lines and regulatory requirements preferred.
•Familiar with Northern California and the Sutter Footprint preferred (preferred practice and managed care experience within the Northern California market) preferred.
Skills and Knowledge
Exceptional writing, research and comprehension skills, with the ability to understand and simplify complex technical, regulatory and contractual information
Excellent presentation skills, able to deliver presentations to various internal/external audiences related to clinical outcomes
Ability to communicate and interact with all levels of the organization, including senior management, compliance/legal, and technical experts throughout the organization, to lead meetings and projects, to provide recommendations and influence project direction and decisions
Ability to build collaborative working relationships with diverse individuals and organizations; strong analytical and problem solving skills; ability to operate independently, confidentially, and to garner confidence from SHP leadership, Sutter affiliates, vendors and consultant staff
Ability to manage competing priorities and tasks, meeting tight timelines through team collaboration, expanded work schedule or prioritizing work
Ability to interpret clinical data within the specific case context
Proficiency in MSWord, PowerPoint, Adobe Acrobat programs
Primary Location: California, Greater Sacramento Area, Sacramento
Organization: Sutter Health Plan
Employee Status: Regular
Position Status: Exempt
Job Shift: Day
Shift Hours: 8 Hour Shift
Days of the Week Scheduled: Monday-Friday
Weekend Requirements: None
Schedule: Full Time
Hrs Per 2wk Pay Period: 80
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 (including possession of a driver's license issued to individuals who did not present proof of authorized presence in the U.S.), age, medical condition, physical or mental disability, military or protected veteran status, political affiliation, pregnancy or perceived pregnancy, childbirth, breastfeeding 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 screening. 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.