Associate Medical Director-Exempt - CCHP

Overview

Contra Costa Health Plan (CCHP) is Contra Costa's single plan Medi-Cal health plan and provides healthcare coverage to over 250,000 members. CCHP is part of Contra Costa Health Services, dedicated to accessible, high-quality, and cost-effective healthcare. This role supports the Clinical Operations Units at CCHP, overseeing utilization management, appeals & grievances, case management, and other clinical departments.

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, contributing to continuous improvement in the quality of care for Medi-Cal members.

• Provide physician oversight to Clinical Departments including but not limited to Utilization Management, Appeals and Grievances, Pharmacy, Case Management.
• Review and make 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.
• Partner with utilization management nurses, pharmacists, care management, and operational leaders to support consistent, evidence-based decision-making and resolve clinical issues during daily operations.
• Participate in and provide clinical expertise to key health plan committees (e.g., Utilization Management, Quality Improvement, Medical Policy) to guide oversight, performance improvement, and compliance activities.
• Support development, review, and implementation of medical policies, clinical guidelines, and workflows to align with current standards of care and regulatory requirements.
• Conduct utilization review and determine medical necessity for inpatient, outpatient, and specialty services in accordance with Medi-Cal, DHCS, CMS, and CCHP policies.
• Oversee fidelity of Clinical Operations in various Clinical Departments (internal auditing of RN and Physician activity).
• Identify opportunities for optimization in Clinical Processes (e.g., building clinical referral pathways, aligning payor and provider activity).

• 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, steps, and final work products.
• Ownership and Accountability
  :
  Holding self and others accountable for high-quality, timely, and cost-effective results.
• Professional Integrity & Ethics
  :
  Honesty and adherence to principles and accountability.
• Oral Communication
  :
  Engaging effectively in dialogue.
• Presentation Skill
  :
  Delivering information to groups.
• Writing
  :
  Communicating effectively in writing.
• Leadership
  :
  Guiding and encouraging others to accomplish a common goal.
• Teamwork
  :
  Collaborating with others to achieve shared goals.

Licenses
:
Possession of a valid physician license issued by the Medical Board of California, and a Board Certification in the specialty applicable for the assignment. Unrestricted current medical license, certification, or registration in CA with DEA licensure. Board Certified in Internal Medicine, Family Practice, Emergency Medicine, or Correctional Medicine.

Experience
:
Three (3) years of full-time experience, or its equivalent, in the practice of medicine. One (1) year in a responsible administrative capacity applicable for the assignment is desirable.

Desirable Qualifications
:

• Strong background in managed care, especially Medi-Cal, Medicare Part D, or D-SNP
• Experience in Epic Electronic Health Record
• Familiarity with regulatory requirements from DHCS, CMS, NCQA, and other oversight bodies
• Strong knowledge of utilization management principles
• Experience in Clinical Case Management, including Chronic Disease Management and inpatient facility discharge planning