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Director, Medical – IPA

AltaMed

This is a Full-time position in New York, NY posted September 14, 2021.

The IPA Medical Director, partnering with the Medical Director of Medical Management, interacts with physicians, staff, health plan staff, staff Medical Directors, CLC Leadership, PODS Medical Leadership and health plan members for leadership, collaboration and when a managed care physicians input is needed or required.

The IPA Medical Director is responsible to be sure that IPA providers comply with Medical Management functions that include Utilization Management, Case Management, and Disease Management Programs, as regulatory agencies require and the IPAs health plan contracts stipulate.

Medical Director shall work collaboratively with the Medical Management, Medical Services and Managed Care Departments to achieve the strategic goals of AltaMed.

Medical Director is also responsible, along with the Managed Care Department, for network adequacy, provider engagement, and provider education Qualifications Must hold a valid, unrestricted license to practice medicine in the State of California, and Board certification in the chosen specialty.

Past UM experience at the IPA or Health Plan level is preferred Have at least three years of clinical practice in direct patient care; and at least three years medical management experience in a managed care setting Responsibilities REFERRAL MANAGEMENT 1.

Monitor ambulatory care utilization trends, communicate to the IPA leadership and providers, and make recommendations to position the organization proactively to manage trends effectively 2.

With the staff, develop and implement action plans, including clinical guidelines, to ensure clinically appropriate and efficient utilization of services 3.

Provide and/or supervise the education, guidance, assistance, and feedback to primary care physicians and specialty panels to achieve appropriate cost-effective patient care 4.

Assess provider network for adequacy of services and make recommendations to staff to address service gaps 5.

Be the final decision maker for the IPA on any denial of payment for outpatient services QUALITY/PATIENT EXPERIENCE 6.

Leads efforts with IPA providers to maximize patient experience (e.g.

as measured by CAHPS), quality (as measured by P4P, HEDIS and CMS 5 Star) and other programs as they become available.

CASE/DISEASE MANAGEMENT and OTHER SPECIAL PROGRAMS 7.

Oversee program implementation and ongoing case and disease management programs, interfacing with case managers and other staff for medical advice and intervention as needed 8.

Monitor utilization trends and communicate program outcomes to IPA leadership and physicians 9.

Promote the appropriate utilization of programs to manage complex and/or catastrophic cases and to promote positive health outcomes through disease management interventions COMMITTEE FUNCTIONS AND LEADERSHIP 10.

Participates in CLC, member of the CQC 11.

As chairperson of the Local PODS supervises local PODS physicians or community physician designees 12.

Participates in Medical Cost Ratio Committee and Fee For Service Committees 13.

Assists the Medical Director, Medical Management, in leading identified clinical initiatives or projects as appropriate, including Appropriate Resource Use Work Groups (ER utilization, Ambulatory Surgical Center Use, Generics) 14.

Attend and provide clinical presentations at IPA Board meetings, General Membership meetings, the Medical Leadership Council, and Physician Advisory committees.

15.

Develop educational programs for the physician network to enhance the delivery of patient care.

NETWORK MANAGEMENT/PROVIDER CONTRACTING 16.

Act as the main point of contact for physicians who wish to speak directly about authorization requests and follow up information 17.

Assess the adequacy of information being provided by the IPA to the IPAs providers and assist in development of any new or revised materials 18.

Assist staff from a clinical perspective in development of fee schedules or payment methodologies 19.

Works collaboratively with the Medical Director of Quality to provide clinical input required for the staff to create and deliver physician performance reports to enhance performance of the physician network CLAIMS/REVENUE RECOVERY 20.

Assist claims processing staff in review of medical claims for unbundling of services or other inappropriate billing practices 21.

Assist claims and revenue recovery staff by reviewing and authorizing cap deductions 22.

Assist the Medical Director of Medical Management in HCC training for IPA providers 23.

Performs all other related duties as assigned.