Director of User Experience Job at Hartmann Lahr in San Francisco

The Community Health Center Network (CHCN), sister organization to the Alameda Health Consortium, is made up of the eight federally qualified community health centers in Alameda County. CHCN functions as the managed care services organization (MSO) for our health centers, contracting with the Alameda Alliance for Health. In order to help our health centers meet their missions of providing the best possible care to their communities, we also provide a broad range of training, technical assistance, quality improvement, information technology, and data analytic services.

Position Title : Medical Director, UM

Reports To : Chief Medical Officer

Classification : Exempt

Status : Part Time Regular (Flexible 60 to 80%)

Salary Range : $138,500 to $196,300

POSITION SUMMARY

The Utilization Management (UM) Medical Director (MD) is an essential member of the medical team, with leadership responsibilities over utilization management and clinical network access. The MD is the primary medical lead for the inpatient UM team, providing clinical oversight for quality assurance, determining medical necessity, and approving denials. They also provide leadership to the outpatient UM team with authorization reviews, referrals for basic case management, and consulting on complex authorizations for medical necessity. As a matrixed clinical leader of the UM department alongside the UM Director, they develop and refine processes to ensure the quality and compliance of the UM program with applicable regulations and standards. They work collaboratively with other medical officers who also carry out UM reviews.

ESSENTIAL POSITION RESULTS

• Advances and develops the strategy and action plans for CHCN’s utilization management program, using leadership, data acumen, and expertise in regulatory compliance to strengthen and advance the organization’s goals.
• Develops and maintains medical officer processes, guidelines and resources for the clinical decision making on authorizations, in accordance with changing regulatory requirements, and in collaboration with the UM Department at CHCN and health plans; conducts regular trainings of medical officers as needed.
• Oversees third party arrangements for independent medical reviews and remote specialty access such as Rubicon MD.
• Assumes primary responsibility for the UM for inpatient care, determining medical necessity, interpreting benefits and limitations, consulting with providers and supporting the inpatient nurse team in their concurrent review of hospitalized members. Leads weekly clinical rounds with CHCN nurses and health plan guests.
• Leads and oversees responsibility for utilization management decisions for outpatient care: determining medical necessity, interpreting benefits and limitations, and consulting with providers.
• Participates in peer-to-peer discussions with providers partners as needed.
• Primary responsibility for the strength of CHCN’s specialty network in collaboration with the Provider Services team. Leads network development with existing and potential specialists and health centers to ensure quality and access.
• Serves on CHCN’s monthly Clinical Committee meetings focused on UM.
• Represents CHCN with our health center partners, external community partners and specialty network, including giving presentations as needed.
• Collaborates with other medical directors and with staff on special projects intended to advance health equity, reduce unnecessary utilization, and improve access to care.
• Represents CHCN and attends regular leadership meetings with health plans, with a leadership focus on UM.
• Medical leadership on the contractual Delegation Agreement, Division of Financial Responsibilities, and compliance.
• Leads and supports investigations on potential clinical quality of care issues, fraud, waste and abuse.
• Contributes to value-based care for members in our network through the development, interpretation and incorporation of reports that provide insight on the under-and over-utilization of services, in collaboration with the Quality Department and Business Analytics.
• Supports and contributes to the quarterly reporting on Health Industry Collaboration Effort (HICE) reports and annual Program Description and Evaluations.
• Actively leads internal and external audits with Compliance and UM leadership, reviews audit responses, and proactively develops and implements audit responses, as appropriate.
• Other duties as assigned.

SUPERVISORY RESPONSIBILITIES

Hires and supervises per diem medical directors.

MINIMUM QUALIFICATIONS

• Leadership skills and experience.
• Sound clinical judgment and ability to evaluate evidence and guidelines around medical treatments.
• Excellent communication skills and ability to work well with a team.
• Highly preferred: Utilization Management experience especially working with complex medical patients; familiarity with Milliman Care Guidelines.
• Computer literacy, especially as it involves synthesis of patient care information.
• Ability to develop new policies and procedures, training nurses or providers on new skills.
• Commitment to underserved populations.
• Exceptional time management and prioritization skills.
• Ability to understand the broader healthcare landscape while being attentive to project details.

Education & Experience

• Active, unrestricted, California medical license and MD / DO from an accredited program in Internal Medicine or Family Medicine. Board certification preferred.
• 5+ years clinical experience, preferably with hospital experience.
• Previous managed care experience preferred; supportive of managed care philosophy; able to manage difficult conversations with professional peers related to medical case review.
• 2+ years working on a team involved with clinical management, preferably in a leadership role.
• Some travel required; a valid California driver’s license and proof of current auto insurance.

General CHCN Roles

• Fosters an environment that promotes trust and cooperation among clients and staff.
• Enforces policies and procedures, including maintenance of client confidentiality, to ensure that the principles of CHCN are implemented.
• Accountable for participating in decision making processes and understanding the outcome(s).
• Understands the values and principles of CHCN and applies them in work responsibilities.
• Participates in outreach activities, agency advocacy, and serves on ad hoc committees, as requested.
• Attends and contributes to CHCN and Board of Directors meetings, as required.

CERTIFICATES AND / OR LICENSES

Medical Board of California, Certified Physician

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this Job, the employee is regularly required to sit and use hands to finger, handle, or feel. The employee is frequently required to talk or hear. The employee is frequently required to stand; walk; reach with hands and arms and stoop, kneel, crouch, or crawl. The employee must occasionally lift and / or move up to 15 pounds. Specific vision abilities required by this job include close vision and ability to adjust focus.

WORKING CONDITIONS AND ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly exposed to an inside environment.

The Community Health Center Network is an Equal Opportunity Employer.

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