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The stated pay scale reflects the range that Sharp reasonably expects to pay for this position.  The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant’s years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.  

What You Will Do
Working with the Chief Medical Officer, oversees medical care for Sharp Health Plan (SHP) products and services and oversees the health care needs of the membership. Serves as a medical manager and policy advisor to SHP and its Chief Medical Officer. Is accountable for and provides professional leadership and direction to the utilization/cost management and clinical quality management functions. Works collaboratively with other plan functions that interface with medical management such as provider relations, member services, benefits and claims management, etc. Assists (as determined by the plan Chief Medical Officer) in short and long range program planning, total quality management (quality improvement), and external relationships. Works with all departments of Health Services to support, provide assistance and direction in overall medical management effectiveness. Reports all issues of clinical quality management to the health plan Chief Medical Officer. To ensure that policies and systems are followed until agreed upon change is implemented. Works toward SHP strategic goals and objectives of ensuring a high quality of medical care for Plan members, staff empowerment, customer satisfaction, cost-effectiveness, and market competitiveness. As a member of the management team, assists in identifying and establishing strategic goals and objectives for the Plan.

Required Qualifications

• Doctor of Medicine (MD)
• Previous experience in the clinical practice of medicine.
• Previous experience as a physician executive in a managed care environment, preferably as an HMO Medical Director.
• California Physicians and Surgeons License - Medical Board of CA -REQUIRED

Other Qualification Requirements

• Board certified in a medical discipline (internal medicine or family practice preferred).

Essential Functions

• Responsible and accountable to the Chief Medical Officer for helping to manage health plan medical costs and assuring appropriate health care delivery for SHP's products and services. Reports organizationally to the Chief Medical Officer.
• Plans, organizes, and directs the professional medical services program, consisting of all primary and Specialty services for in-patient, out-patient, preventive and wellness programs.
• Implements health plan medical policies, goals and objectives.
• Provides professional leadership and direction to the functions within the Medical Management
• Department (Utilization/Cost Management and Quality Management)
• Responsible for and assists with the development of staffing plans and assuring the adequate allocation of resources to the medical management functions.
• Responsible and accountable for implementing the Utilization/Cost Management Program and Quality Improvement Program, in conjunction with the Manager Medical Management and Quality Improvement Manager.
• Assists the Chief Medical Officer with activities to promote positive community relations.
• Assures plan conformance with legal and regulatory requirements
• Assists the Chief Medical Officer and the Quality Improvement Manager in creating and maintaining a system that gives feedback to providers individually and collectively regarding managed care effectiveness of individual providers and networks.
• Assists the Chief Medical Officer in designing and implementing corrective action plans to address issues and improve plan and network managed care performance.
• Collaborates with Chief Medical Officer in creating and maintaining programs that incentivize providers to achieve selected utilization/cost and quality outcomes.
• Participates in policy review, performs analysis and makes recommendations.
• Participates in the retrospective review and analysis of Plan performance from summary data of paid claims, encounters, authorization logs, complaint and grievance logs and other sources.
• Achieves and maintains benchmarked utilization and cost management (UM) goals and clinical quality improvement (QI) objectives, in conjunction with the Manager Medical Management and Quality Improvement Manager.
• Provides periodic written and verbal reports and updates as required in program descriptions, Annual Work Plans and policy and procedures to various plan committees, and the SHP Chief Medical Officer.
• Supports NCQA qualification activities. Prepares for site visits and responds to accrediting and regulatory agency feedback.
• Supports pre-admission review, utilization management, and concurrent and retrospective rev1ew process.
• Participates in risk management, pharmacy utilization management, catastrophic case review, outreach programs, HEDIS reporting, site visit review coordination, triage, provider orientation, credentialing, profiling, etc.
• Conducts quality improvement and outcomes studies as directed by the Quality Management Committee, Peer Review Committee and Chief Medical Officer and reports findings in conjunction with the Quality Improvement Manager.
• Participates in the grievance process with the Chief Medical Officer, insuring a fair outcome for all members.
• Monitors member and provider satisfaction survey results and implements changes as needed to increase satisfaction and assure that satisfactory relationships are maintained between network and plan participants.
• Participates in SHP Advisory Committees which include (but are not limited to) the Peer Review Committee and the Quality Management Committee.
• Participates in key marketing activities and presentations, as requested.
• Promotes wellness and ensures programs of prevention, education and outreach to members and providers are consistent with SHP's mission, vision and values.
• Maintains up-to-date knowledge of new information and technologies m medicine and their application to SHP.
• Performs and oversees in-service staff training and education of professional staff.
• Represents SHP at medical group meetings, conferences, etc.
• Participates in the development of strategic planning for existing and expanding business. Recommends changes in program content in concurrence with changing markets and technologies.
• Participates in key marketing activities and presentations, as necessary, to assist the marketing effort, as requested.
• Ensures that the Utilization Management staff is available on a 24 hour basis to respond to authorization requests for emergency and urgent services and is available, at a minimum, during normal working hours for inquiries and authorization requests for non-urgent health care services..
• Performs other duties as requested or assigned.
• Collaborates with the Manager, Medical Management to guide and direct staff in relation to medical issues and departmental responsibilities. Assists in monitoring, reviewing, and evaluating the quality of health care services provided and the appropriateness of health care resources utilized, and communicates with PMGs and Plan providers as needed. Addresses physicians' issues and educates providers with regard to Plan policy as needed.
• Completes and/or supervises the completion of all clinical appeals and grievances. Collaborates with Customer Care Manager to identify trends in grievances. Supervises the process for identifying Potential Quality Issues.
• Supervises Physician Reviewer(s)
• Shares after-hours coverage responsibilities with other physicians
• Assists the CMO, as needed, to oversee the credentialing process.
• Assists in the development and interpretation of the covered benefit provisions of member materials and Plan contracts. Assists in the development and implementation of new benefits packages.
• Maintains appropriate contacts with membership in community and professional organizations.

Knowledge, Skills, and Abilities

• Strong clinical background and skills.
• Solid understanding of utilization management and quality assurance activities and concepts.
• Excellent communication skills, both verbal and written.
• Strong interpersonal skills, including the ability to interface effectively with employees, members, physicians, senior management, and the public at large.
• Management skills to meet the organizational goals.
• Knowledge of regulatory and accreditation agencies and requirements.
• Able to manage multiple priorities and deadlines in an expedient and decisive manner.
• Able to manage difficult peer situations arising from medical care review.
• Appreciation of cultural diversity and sensitivity towards target population.

Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class

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