Associate Medical Director-Exempt - CCHP

Overview

Associate Medical Director-Exempt - CCHP

Salary: $ - $ Annually

Closing Date:
Continuous

Why join the Contra Costa Health Services Department?

Contra Costa Health Plan (CCHP) is Contra Costa's single plan Medi-Cal health plan and provides healthcare coverage to over 250,000 members, the majority of whom are Medi-Cal beneficiaries. CCHP is part of Contra Costa Health Services, which is dedicated to providing accessible, high-quality, and cost-effective healthcare to the residents of Contra Costa County. As a member of CCHP, you will contribute to an organization that prioritizes health equity, innovation, and the highest standards of patient care.

By joining our team, you will be part of a dynamic and collaborative environment where your expertise will help improve the health outcomes of the community.

Clinical Operations Units at CCHP oversee critical functions like Utilization Management (UM), Appeals & Grievances, Case Management, and other clinical departments. The division ensures that all clinical decisions meet regulatory standards while promoting the efficient and effective delivery of healthcare services. In this role, you will help lead and guide the clinical operations teams, providing oversight and expertise in areas such as UM determinations, medical appeals, and grievances.

Your work will support continuous improvement in the quality of care for our Medi-Cal members.

We are looking for someone who is:

• A strong communicator
• Detailed-orientated and organized
• Solution-focused and adaptable
• Knowledgeable in regulatory & compliance requirements
• Skilled at delegating and has strong oversight skills
• Able to work independently and is self-directed

What you will typically be responsible for:

• Providing physician oversight to Clinical Departments including but not limited to Utilization Management, Appeals and Grievances, Pharmacy, Case Management

Reviewing and making final clinical decisions on appeals and grievances, including complex and high-risk cases, ensuring decisions are timely, well-documented, and defensible from a regulatory and clinical standpoint

• Partnering closely with utilization management nurses, pharmacists, care management, and operational leaders to support consistent, evidence-based decision-making and to resolve clinical issues that arise during daily operations
• Participating in and providing clinical expertise to key health plan committees, such as Utilization Management, Quality Improvement, and Medical Policy committees, helping to guide oversight, performance improvement, and compliance activities
• Supporting the development, review, and implementation of medical policies, clinical guidelines, and workflows to ensure alignment with current standards of care and regulatory requirements
• Conducting utilization review & making medical necessity determinations for inpatient, outpatient, and specialty services in accordance with Medi-Cal, DHCS, CMS, and CCHP policies
• Overseeing fidelity of Clinical Operations in various Clinical Departments (internal auditing of RN and Physician activity)
• Identifying opportunities for optimization in Clinical Processes (e.g. building clinical referral pathways, building synergy between payor and provider activity)

A few reasons you might love this job:

• You will work alongside passionate professionals who are committed to health equity, community wellness, and improving outcomes for underserved populations
• This role allows you to directly improve the health of vulnerable communities, making a tangible difference in people’s lives
• You will work with a diverse team of healthcare professionals, gaining insights into various aspects of the healthcare system
• You will have the chance to lead initiatives, shape policies, and grow professionally in a strategic role

A few challenges you might face in this job:

• Navigating the ever-changing payor regulations (for both Medi-Cal and Medicare) and ensuring compliance with state and federal policies can be challenging and time-consuming
• Managing expectations and aligning the goals of various stakeholders
• The role can be high-pressure, with tight deadlines and the constant need to make quick decisions, especially during busy periods or policy changes

Required Competencies:

• Critical Thinking: Analytically and logically evaluating information, propositions, and claims
• Decision Making: Choosing optimal courses of action in a timely manner
• Fact Finding: Obtaining facts and data pertaining to an issue or question
• Legal & Regulatory Navigation: Understanding, interpreting, and ensuring compliance with laws and regulations
• Professional & Technical Expertise: Applying technical subject matter to the job
• Attention to Detail: Focusing on the details of work content, work steps, and final work products
• Displaying Ownership and Accountability: Holding self and others accountable for measurable high-quality, timely, and cost-effective results
• Professional Integrity & Ethics: Displaying honesty, adherence to principles, and personal accountability
• Oral…