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.
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.
Experience & Education:
Medical Doctor degree from a fully accredited university.
Board Certification, preferably in an area of Primary Care such as Pediatrics, Family Practice, or Internal Medicine.
Current, valid, unrestricted California Physician & Surgeons’ License.
Physician leader with demonstrated record of leading and implementing medical management in a managed care organization.
Medicare and Medicaid experience strongly preferred.
Experience in NCQA accreditation and CMS star ratings within a health plan preferred.
Medi-Cal and Medicare managed care including understanding of contracts and at-risk arrangements with providers.
Industry and professional standards of health care, utilization management, quality improvement and other medical management functions.
Principles and techniques of effective human resource management, including training and evaluation and effective utilization of staff.
Financial reporting, budgeting and operational management.
Principles and practices of healthcare, health care systems, and medical management.
Required governmental and other reporting criteria (i.e. NCQA, HEDIS).
Internal Number: 96260
Better. Together.Our mission is to provide members with access to quality health care services delivered in a cost-effective and compassionate manner. CalOptima is a county organized health system that administers health insurance programs for low-income children, adults, seniors and people with disabilities in Orange County.As Orange County’s largest health insurer, we provide coverage through four major programs:**Medi-Cal (California's Medicaid Program) for low-income children, adults, seniors and people with disabilities , seniors and persons with disabilities**OneCare (HMO SNP) (a Medicare Advantage Special Needs Plan) for low-income seniors and people with disabilities who qualify for both Medicare and Medi-Caldisabilities who qualify for both Medicare and Medi-Cal**PACE (Program of All-Inclusive Care for the Elderly) for older adults, providing comprehensive health services through the CalOptima PACE center**OneCare Connect Cal MediConnect Plan (Medicare-Medicaid Plan) for people who qualify for both Medicare and Medi-Cal, combining Medicare and Medi-Cal benefits, adding supplemental benefits for vision, transportation and dental services, and providing comprehensive care c...oordination“Better. Together.” is our motto, but it’s also our philosophy. We believe that by working together, we can make things better – for our members and community.