• Director, Medical - IPA

    Location US-CA-Los Angeles
    Job ID
    2018-6160
    Category
    Management
  • Overview

    The IPA Medical Director, partnering with the Medical Director of Medical Management, interacts with physicians, staff, health plan staff, staff Medical Directors, CLC Leadership, PODS Medical Leadership and health plan members for leadership, collaboration and when a managed care physician's input is needed or required. The IPA Medical Director is responsible to be sure that IPA providers comply with Medical Management functions that include Utilization Management, Case Management, and Disease Management Programs, as regulatory agencies require and the IPA's health plan contracts stipulate. Medical Director shall work collaboratively with the Medical Management, Medical Services and Managed Care Departments to achieve the strategic goals of AltaMed. Medical Director is also responsible, along with the Managed Care Department, for network adequacy, provider engagement, and provider education

     

    Responsibilities

    REFERRAL MANAGEMENT

    1. Monitor ambulatory care utilization trends, communicate to the IPA leadership and providers, and make recommendations to position the organization proactively to manage trends effectively
    2. With the staff, develop and implement action plans, including clinical guidelines, to ensure clinically appropriate and efficient utilization of services
    3. Provide and/or supervise the education, guidance, assistance, and feedback to primary care physicians and specialty panels to achieve appropriate cost-effective patient care
    4. Assess provider network for adequacy of services and make recommendations to staff to address service gaps
    5. Be the final decision maker for the IPA on any denial of payment for outpatient services

    QUALITY/PATIENT EXPERIENCE

     

         6. Leads efforts with IPA providers to maximize patient experience (e.g. as

             measured by CAHPS), quality (as measured by P4P, HEDIS and CMS 5 Star)

             and other programs as they become available.

     

    CASE/DISEASE MANAGEMENT and OTHER SPECIAL PROGRAMS

     

          7. Oversee program implementation and ongoing case and disease

              management programs, interfacing with case managers and other staff for

              medical advice and intervention as needed

          8. Monitor utilization trends and communicate program outcomes to IPA

              leadership and physicians

          9. Promote the appropriate utilization of programs to manage complex and/or

              catastrophic cases and to promote positive health outcomes through disease

              management interventions

     

    COMMITTEE FUNCTIONS AND LEADERSHIP

     

          10. Participates in CLC, member of the CQC

          11. As chairperson of the Local PODS supervises local PODS physicians or

                community physician designees 

          12. Participates in Medical Cost Ratio Committee and Fee For Service

                Committees

          13. Assists the Medical Director, Medical Management, in leading identified

                clinical initiatives or projects as appropriate, including Appropriate

                Resource Use Work Groups (ER utilization, Ambulatory Surgical Center

                Use, Generics)

          14. Attend and provide clinical presentations at IPA Board meetings, General

                Membership meetings, the Medical Leadership Council, and Physician

                Advisory committees.

          15. Develop educational programs for the physician network to enhance the

                delivery of patient care.

     

    NETWORK MANAGEMENT/PROVIDER CONTRACTING

     

          16. Act as the main point of contact for physicians who wish to speak directly

               about authorization requests and follow up information

          17. Assess the adequacy of information being provided by the IPA to the IPA's

                providers and assist in development of any new or revised materials

          18. Assist staff from a clinical perspective in development of fee schedules or

               payment methodologies

          19. Works collaboratively with the Medical Director of Quality to provide clinical

               input required for the staff to create and deliver physician performance

               reports to enhance performance of the physician network

     

    CLAIMS/REVENUE RECOVERY

     

          20. Assist claims processing staff in review of medical claims for unbundling of

               services or other inappropriate billing practices

          21. Assist claims and revenue recovery staff by reviewing and authorizing cap

               deductions

          22. Assist the Medical Director of Medical Management in HCC training for IPA

                providers

          23. Performs all other related duties as assigned.

     

    Qualifications

    1. Must hold a valid, unrestricted license to practice medicine in the State of California, and Board certification in the chosen specialty.
    2. Past UM experience at the IPA or Health Plan level is preferred
    3. Have at least three years of clinical practice in direct patient care; and at least three years medical management experience in a managed care setting

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