The SMA Medical Director provides leadership for the acute management processes ensuring appropriate decisions are made that are in alignment with performance metrics for the on the management of its patient populations . The Medical Director will also act as a liaison with the SMA Hospitalists and PCPs as well as the network Hospitalist groups by providing education regarding medical management processes and operating procedures including; Milliman guidelines, Observation process, medical management principles, grand rounds, coordinating the patient transition to post acute stytem and will work closely with SMA Primary care and specialist. Will intervene and engage in conflict resolution between the Hospitalists and PCPs. Will educate and interact with clinical and case management staff regarding utilization practices and effective resource management. Provide medical decisions for prior authorization as required for inpatient, post acute and outpatient requests.
Position in this function manage the clinical review of long stay cases in acute setting with case management team and attending providers. Recommend services within the organization for discharge planning including assistance with home care, palliative, LTAC, SNF for bridges towards wellness. Shorten OBS cases with services to support discharge as well as prevention for readmission.
Primary Responsibilities:- Provide guidance and direction to physicians and nurses regarding all aspects of medical care and multi-levels transitions of care
- Oversee TOC processes to ensure reduction in readmission
- Analyze data to identify trends and opportunities towards success measures of the command center
- Support overall regional and corporate goals to ensure continued growth, safety of the members and profitability
- Participate in strategic development and implementation of best practices for the command center
- Educate physicians and nurses on resources and intercede when company resources are not performing towards their operation expectations
- Establish relationships with employed and network hospitalist groups to promote the goals of the command center
- Participate and guide clinical care towards Optum protocols
- Report, collaborate and implement plans as directed with the Sr. Medical Director
You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications:- MD/DO Board Certified in a post graduate clinical specialty
- MD/DO Licensed State of NV (or ability to obtain)
- 5+ years related professional experience in managed care environment
- 4+ years of related supervisory/management experience
Preferred Qualifications:- Experience in Hospital setting
- Knowledge of Medicare coverage criteria
- Demonstrated excellent medical management, leadership skills and excellent communication skills
- Proven good skills in making presentations and teaching
- Proven solid organizational and prioritization skills
- Proven ability to make medical necessity decisions based on Medicare coverage criteria
- Proven to integrate guidelines/tools to negotiate most effective plan of care
- Proven to formulate plans that incorporate the health plan benefits, community services, and patient self-direction
Working Conditions:- Work in office and in acute hospital and/or sub-acute to develop relationships with the hospital attending physicians and hospital administrative staff
- Driving up to one hour per day
Competencies for High Performers: - Participation in departmental projects assigned by Sr. Medical Director
- Metric measures of success: Admission/K, Readmissions/K and Observation rate discharge, LOS Observation Rate. Observation rate of engagement with high-risk patients, improved readmission rate of high-risk patients (10 days) and engagement of PCP HFU rate
Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $248,500 - $373,000 annually based on full-time employment. We comply with all minimum wage laws as applicable."
