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Senior Medical Director - Sharp Community Medical Group

Job ID 112739 Date Posted 09/10/2021
San Diego, California
  • Sharp HealthCare
  • SCMG HSM Administration
  • Day Job
  • Full-Time
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Responsibilities

Senior Medical Director -Sharp Community Medical Group (SCMG)

Summary:

The Senior Medical Director position is accountable for providing medical management and leadership to Sharp Community Medical Group (SCMG) to ensure the delivery of high quality, customer responsive and cost-effective medical care on behalf of SCMG, and its members through a network of private practice physicians.

Required Skills and Qualifications:

  • Minimum of five (5) years’ experience in clinical practice in both a managed care and fee-for-service setting.
  • Minimum of five (5) years’ experience as a Medical Director in a Health Plan, Medical Group, or IPA.
  • Experience in the operations of a prepaid delivery system.
  • Experience in the Performance Measurement arena.
  • Experience in identifying opportunities, developing and implementing plans, and evaluating results in various areas.
  • In-depth experience with Regulatory, Legislative, and Accreditation Standards.
  • Excellent knowledge and operational experience within a Hospital Integrated System.
  • Experience in public speaking to small and large audiences.
  • Experience in educating peers and employees, gaining buy-in and motivating people.

Education: 

  • Doctor of Medicine (MD) degree or Doctor of Osteopathic Medicine (DO) degree  required.
  • MBA degree is preferred.

Licensure:

  • Current California state license to practice medicine without restriction.
  • California Physicians and Surgeons License is required.
  • Medical Board Certification required.

Essential Functions:

  • Integration and oversight of the medical management departments of Health Services Management (HSM), including Utilization Management, Quality Management, Training and Compliance, Chronic Care Management, Disease Management, Care Management, Appeals and Grievances and Pharmacy.
  • Direct supervision, strategy development, and budgetary responsibility for the Medical Director Administrative department. Direct supervision of Regional Medical Directors.
  • Development, identification and oversight for medical guidelines to demonstrate medical group integration for SCMG’s PPO strategy.
  • Acts as a senior clinical reviewer of medical claims review to determine medical necessity, appropriateness of provider services, interpretation of benefits and limitations, and review of claims.
  • Develops and implements guidelines and provides input on day-to-day medical care review on issues involving prior authorization, concurrent review and retrospective review through direct physician and health plan interaction to ensure cost effective, quality care for members.
  • Participates in and performs benefit interpretation and criteria development on an ongoing basis with health plans, physicians and various departments within SCMG.
  • Communicates with health plan clients and medical directors on utilization function.
  • Direct oversight for SCMG’s Align Measure Perform (AMP) Value Based Pay Initiative to include identification of opportunities, initiative development and implementation to maximize AMP revenues.
  • SCMG liaison to all health plans for clinical utilization, quality, compliance, out of network, appeals and grievances, risk management, and specialty items.
  • Develops and implements education tools and forums for physicians in Performance Enhancement Model for Quality and Financial success of individual practices.
  • Participates as senior clinical resource with system integration for improved UM and QM standardization processes and actively seeks cost savings opportunities which promote increased quality care to members and improved operations for physicians and staff.
  • Senior SCMG clinical representative and active participant in regional, hospital and physician meetings.
  • Serve as senior medical representative to SCMG’s Executive Committee and Board of Directors and as medical advisor to SCMG’s upper management team (CEO, CFO, and COO).

Skills, Knowledge and Abilities:

  • In-depth knowledge of medical care delivery systems, utilization management, quality assurance, peer review, contracting, benefits interpretation, provider relations, and member services.
  • Excellent interpersonal and persuasive communications skills along with leadership skills.
  • Ability to manage for positive results in all areas.
  • Excellent analytical and negotiation skills.
  • Recognized and well regarded for high ethical and professional standards.
  • Proven track record.

Compensation and Benefits:

The position provides a very competitive compensation, including opportunity to participate in a management bonus incentive program along with a generous benefit package.

 

Please note: Unsolicited resumes from employment agencies or other third parties will not be considered.

 

“Sharp HealthCare is an Equal Opportunity/Affirmative Action Employer, we celebrate our employees’ differences.  All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, disability, gender, gender identity, transgender status, sexual orientation, protected veteran status, among other things, or status as a qualified individual with disability.

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