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
Internal Number: SHP-1825332
About Sutter Health Plus
Sutter Health Plus is an HMO health plan affiliated with not-for-profit Sutter Health. We offer affordably priced health plans to individuals and employers in the greater Sacramento, Central Valley and Bay Area communities. Our provider network includes many of Sutter Health’s nationally respected and recognized hospitals, physician organizations, surgery centers, outpatient lab sites, urgent care centers and other health care services.We offer a variety of health plan options to help individuals and employers meet their needs and budgets. Plan designs include traditional, deductible and high-deductible health plans. We provide coverage for hospitalization, outpatient services, prescription drug coverage and no out-of-pocket cost preventive services. Optional benefit plans include coverage for dental, vision, acupuncture and chiropractic services. Sutter Health Plus—your partner for good health.