Kaiser Permanente Nevada - Medical Director, Utilization and Referral Management and Authorizations

Kaiser Permanente Nevada - Medical Director, Utilization and Referral Management and Authorizations Kaiser Permanente Nevada is currently seeking a Medical Director for Utilization and Referral Management and Authorizations. This position will require a Board Certified or Board Eligible Family Medicine or Internal Medicine trained physician(s) with a 0.5-0.7 clinical FTE and 0.3-0.5 administrative FTE. Qualifications • Required: Medical Degree MD/DO • Required: BC/BE Family Medicine or Internal Medicine • Ability to obtain: Unrestricted Federal DEA • Ability to obtain: Nevada State Medical License • Required: BLS or ACLS required • Salary is commensurate upon FTE and experience • Sign-on bonus: 200k pro-rated to FTE • Leadership stipend REPORTS TO Executive Medical Director, Health Plan Functions JOB SUMMARY The Medical Director role is responsible for a wide set of clinical and operational services-as outlined below-that through clinical leadership and vision, will enable Kaiser Permanente Nevada (KP Nevada) to build world class quality, service, and affordability outcomes. By working collaboratively across departments to implement improvements, the role will help lead the unified KP NV goals in the areas of referral and review services, utilization management, medical policy review, case management and emergency medical services (EMS). This role oversees the effectiveness, efficiency, quality and clinical ownership of divisions rolling up to them, ensuring work aligns to the Kaiser Medical Foundation (KPMF) strategic needs and outcomes. PRINCIPAL DUTIES & RESPONSIBILITIES Responsibility Description Strategic Direction • Implement KPNV business strategies and initiatives with the KPMF direction. • Set high standards for themselves and the medical group, both around performance and around leadership style. Lead with integrity and respect. • Represent KP NV to a variety of audiences both internal and external. • Oversee the effectiveness, efficiency, service and quality outcomes of the medical, clinical, and business units that roll up to this leader. This includes: o The referral management unit o Review services (preservice, RRG) o The clinical review unit (CRU) o Provider reconsiderations o Health plan UM activities and appeals in conjunction with Kaiser Foundation Health Plan of NV partners o The division of EMS services, and case management o Medical policy Leadership and Teambuilding • Oversee the EMS medical director on supporting novel initiatives and goal setting in the EMS space. • Oversee Medical Policy medical director. • Oversee the Case management medical director. • Support a high performing medical group by setting clear expectations, reviewing outcomes, managing performance, and rewarding excellence. Operational Excellence and Quality • Oversee clinical and physician operational leaders in the areas reporting to them and ensures that those leaders and teams are leading work that is: 1. Aligned with our clinical intent, and 2. Meets the needs of our members in terms of the service experience and quality. • Ensure teams meet the KPMF standards for review timelines and quality. • Work with the CRU medical director and Mental Health and Wellness (MHW) Associate Medical Director to participate in the adjudication of hospital admission denials from Utilization Review and organizes CRU MD participation at weekly concurrent review meetings. Ensures weekend coverage for inpatient reviews as well as time sensitive outpatient reviews. • Act as an expert liaison for KP NV treating providers and administrators who have complex utilization questions/issues, some of which are high profile and urgent. Able to respond to these issues in a timely and professional manner. • Participate in various process improvement projects. • Help bring on new medical policy initiatives and present resource requests to leadership. • Utilize daily management system and operational excellence approach to daily work and escalation resolution. • Meet KP NV compliance and code of conduct requirements. • Ensure the Integrated Delivery System and Enterprise are successful by being an active, engaged, responsible partner in a variety of partnerships. • Identify situations when benefit language is vague or contradictory, leading to difficulties with medical review decisions and forward these to the Benefits Committee. • Provide consultation to local District and Specialty Medical Directors related to clinical review and review criteria and work with providers and staff to educate and orient them to the review criteria and process. • Promote and support professional development and career satisfaction of front-line MD teams. • Participate in the selection, evaluation, performance improvement, and recognition of providers. • Initiate team meetings and one-on-one meetings with direct reports on an agreed-upon cadence. • Meet annually with direct reports to review their individual development plans. • Initiate, implement, and monitor Performance Improvement plans (PIPs) with support and assistance of management and Human Resources. • Develop other leaders in the department and succession planning in partnership with Human Resources. • Accountable for performance management in collaboration with Senior Leadership. Specific responsibilities include training, scheduling, selection, and orientation of new staff, setting expectations, giving feedback, recognizing excellence, promoting skill development, conducting performance evaluations and management, and celebrating successes of the medical group members. Financial Stewardship • Understand FTE and budget. • Define optimal practice environment (tools, processes, equipment, etc.) to promote highly efficient physician practices, including review of all EWEP and stipends. • Review and monitor all expenses, whether internal or external, and work across clinical sites and service areas to develop strategies that reduce overall costs. • Participate and inform complimentary efforts in design and contracting as led by the Health Plan. • Define the capital needs of the clinical department and program to ensure they have the tools needed to deliver quality care to our patients. • FTE management and subspecialty decisions and partnership meetings will be done in accordance with both dyad partners and KP NV Business partner. Other Skills and Knowledge • Understanding of utilization review, case management, pathway development and management, and quality management. Good listening, writing and speaking skills. Ability to lead teams in program planning, implementation, and monitoring. Demonstrated skills in Lean RPIW processes. • In addition to the above, knowledge of regulatory and certification requirements which impact utilization management, case management, referral management, and care coordination program design. Other duties as assigned. JOB SPECIFICATIONS EDUCATION REQUIRED DESCRIPTION PREFERRED Minimum: Medical degree plus completion of approved residency/fellowship training in Internal Medicine or Family Medicine Experience in a health care business leadership role not including required experience below. Completion of approved residency program MBA, MHA, MMM or similar master's program Documentation of additional training in Health Plan Review, Utilization Management, and Quality Programs EXPERIENCE REQUIRED DESCRIPTION PREFERRED Minimum: 5 years of clinical practice, including active hospital rounding, with 3 years of experience in utilization/quality management and/or health plan medical director experience 5 to 7 years' experience in clinical practice with an additional 5 years' experience in utilization/quality management, some of which has been associated with Health Plan Management Experience leading teams in analysis, planning, implementation and monitoring the implementation of new programs and processes, in addition to case management, utilization management, and/or pathway management program teams LICENSES, CERTIFICATIONS OR OTHER ESSENTIAL QUALIFICATIONS REQUIRED DESCRIPTION PREFERRED Minimum: Board Certified by ABMS or other appropriate certifying agency in Internal Medicine or Family Medicine Current unrestricted appropriate Nevada State license and credentialed by KP NV Nevada Permanente Medical Group Shareholder in Good Standing Board Certified by "program specific accreditation" or another appropriate accreditation Meets KP NV performance standards for quality, service, access, coding and documentation Maintains Board Certification and seeks to maintain knowledge of major advances in the practice of medicine and within specialty area None COMPETENCIES Competencies: Skills, Knowledge & Behaviors that are required for performing the job. COMPETENCIES DESCRIPTION REQUIRED/PREFERRED Management Demonstrated leadership skills with the ability to direct the activities of others on a direct or matrix team basis. Ability to collaborate and be influential across structures and roles. Possesses high professional standards and maintains respect of provider colleagues, demonstrated understanding of the changing medical environment such as medical/legal issues, staff concerns, customer demands, sensitivity to timing, etc. Celebrate successes, recognize excellence in performance, and communicate accomplishments to build pride. Develops cultural competency and agility in self and others in order to Understand and respond to the different care experiences faced by our diverse patient population. Takes a leadership role to "walk the talk" and models goal-oriented, collaborative high performance. Actively promote KP NV as the best place to practice and receive care within KP NV and to the community. Understands the fundamentals of bias and is able to take this into account as a leader. Understands the value of diverse teams and demonstrates commitment to diversifying the medical group and leadership. Ability to challenge established ways and lead change. Model and promote an effective partnership within KPMF. Required Delivery Systems Knowledge of delivery system operations, healthcare delivery systems and trends. Required Business Acumen Knowledge of business processes and rapid cycle improvement and systems thinking. Knowledgeable about care delivery across the continuum. Expertise with MS Office (Word, Excel, etc.). Ability to participate in activities to maintain knowledge of major advances in the practice of medicine through attendance of external conferences, educational seminars and involvement in professional association activities. Ability to participate in activities to enhance knowledge of administrative operations through educational efforts and involvement in professional association activities. Required Decision Making Communication Demonstrated effective problem solving and decision-making skills. Proven negotiation and conflict resolution skills. Excellent communication skills. Ability to translate and communicate KP NV's mission, vision and performance to staff. Encourages front line staff to improve care where they work. Required Human Resource Skills Financial and human resource management skills; demonstrated success working with medical staff. Demonstrated success modeling KP NV's Principles and Core Behaviors: • Care: Respectful, Collaborative, Engaging • Serve: Inspiring, Accountable, Inclusive • Impact: Committed, Courageous, Interconnected Required Project Management Project management and data analytics skills. Preferred Community Reno and Sparks Nevada Our Inclusive Workforce Kaiser Permanente is committed to an inclusive workforce culture. Kaiser Nevada has a focus on supporting all our physicians and professional staff in an inclusive environment, identifying community healthcare disparities, and providing education and tools to provide culturally responsive care to mitigate these disparities. If you have an interest in joining our inclusive workforce culture, we encourage you to apply and become a part of our mission to improve the health of our members and the communities that we serve.