Position Summary:

Oversees medical care delivery system, including development and implementation of strategies, programs, policies and procedures for all medical services. Establish standards for evaluating providers for inclusion in CalOptima program and for the on-going performance of participating providers. Responsible for determinations of medical necessity and appropriateness of medical services. Works with Directors and Medical Directors in the operational oversight of the medical division, including: Quality Improvement, Quality Analytics, Utilization Management, Case Management, Disease Management, Health Education, Pharmacy Management, Long-Term Services and Supports, Behavioral Health Integration Enterprise Analytics, Program of the All-Inclusive Care for the Elderly (PACE) and other medical management programs.

Position Responsibilities:

• Ensure the CalOptima mission, to provide members with access to quality health care services delivered in a cost-effective and compassionate manner.
• Oversee functional areas including Utilization Management, Quality Management, Case Management, Disease Management, Long-Term Services and Supports, Pharmacy, Behavioral Health, Health Education, Credentialing, and PACE.
• Prepare materials for and participate in public meetings including Board of Directors, Quality Assurance Committee, Provider Advisory Committee, Member Advisory Committee.
• Maintain and improve CalOptima’s National Committee on Quality Assurance (NCQA) accreditation scores and Centers for Medicare & Medicaid Services (CMS) ratings.
• In collaboration with other departments, develop and implement effective programs.
• Ensure Medical Affairs is fully prepared for all regulatory and NCQA routine audits.
• Recruit, develop, and retain a strong management team within Medical Affairs.
• Work effectively and collaboratively with the CalOptima senior leadership team.
• Represent CalOptima to state and federal regulators, accreditation organizations and other local and national health care professional organizations, associations and partnerships.