Associate Medical Director-Exempt - CCHP

Overview

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.

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)

Minimum Qualifications

License

Required:

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

Application Filing: Interested individuals should submit an online application and provide all required documentation to be considered. Those candidates deemed most qualified will be invited to interview.

This position is exempt from the merit system…