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Senior Medical Director

San Francisco Health Plan

San Francisco Health Plan

San Francisco, CA, USA
Posted on Friday, April 12, 2024

Under the direction of the Chief Medical Officer, the Senior Medical Director is responsible for clinical oversight and management of all SFHP Utilization Management (UM) and Quality Improvement functions. The Senior Medical Director works in partnership with VP Health Services Programs to shape the strategic direction, implement new initiatives, ensure regulatory compliance and execute key clinical functions of these departments. This position serves as a teacher and mentor to Medical Directors and clinical staff to foster professional growth and development.

Key areas of focus include:

  • Develop and implement clinical programs to align with SFHP’s strategic priorities in order to improve quality of care and outcomes for members.
  • Provide leadership in developing and implementing UM Strategy and Program.
  • Provide leadership and oversight in Quality Improvement strategy, including HEDIS and CAHPS.
  • Lead the clinical team and provide clinical oversight, direction and mentoring.
  • Develop and increase collaborative relationships with external partners and stakeholders evidenced by improved clinical performance metrics.
  • Monitor network performance proactively to ensure adherence to health plan standards, and execute initiatives to address issues affecting performance.
  • Assure interdepartmental collaboration and communication with provider contracts, provider relations and claims and others resulting in a quality network of providers.

SFHP proudly offers a hybrid work environment. As such, this role will be required to be on-site and in office a minimum of 4 days per month.

Salary Range: $312,000 - $346,000

WHAT YOU WILL DO

  • Identify areas of risk and opportunities to optimize utilization management.
  • Participate in a formal Utilization Management Program for the Plan and its Providers.
  • Develop and execute solutions to monitor Utilization Management.
  • Lead and develop Quality Improvement strategy around HEDIS and CAHPS, in collaboration with the Population Health Management team.
  • Consult and advise on the development of protocol, procedures, oversight and training in the following areas:
    • Pharmacy
    • Pre-admission authorization
    • Prospective, concurrent (inpatient) and retrospective review
    • Long Term Care Services and Support including Skilled Nursing and Subacute care
    • Inpatient claims review
    • Utilization/Medical Management review reporting and evaluation
    • SFHP led Member Case Management
    • Potential Clinical Quality Issues
    • Grievance resolution
  • Actively participates and provides physician leadership in the following SFHP Committees.
    • Utilization Management Committee
    • Grievance Review Committee
    • Pharmacy and Therapeutics Committee
    • Quality Improvement Committee
    • Participates on the Pharmacy and Therapeutics Subcommittee
    • NCQA Accreditation
  • Provide physician leadership and clinical support for the following areas: Grievance and Appeals, Care Management, Potential Quality Issues.
  • Provide physician leadership and clinical support for NCQA activities of the Plan.
  • Provide physician leadership for UM and CM Delegation oversight activities of the Plan, including Behavioral Health.
  • Understand and advise the day-to-day clinical operations of the Plan, and links respective business operations / business strategy with outcomes.
  • Model data-driven leadership, ensuring interventions are measured and evaluated for efficacy and impact.
  • Promotes and furthers SFHP’s culture and mission by fostering an environment where all staff are recognized, understood, appreciated and embrace inclusion and belonging.

WHAT YOU WILL BRING

  • 5 years of post-residency experience in a recognized medical specialty, which must have included at least (3) years of managed care experience. Preferred experience is in adult primary care, such as family practice or internal medicine.
  • Experience working with clinical practice guidelines and evidenced based criteria sets.
  • Experience leading Quality Improvement efforts.
  • Possesses strong knowledge of Managed Care principles, utilization and case management programs and has exposure to working with regulatory agencies.
  • Knowledge of CMS and Medicaid regulations preferred; Medical Director for an IPA, medical group or HMO highly desirable
  • MD/DO degree from an accredited program, with an active, unrestricted California medical license.
  • Board certification.
  • A current CA license to practice without restriction.
  • 3-5 years of supervisory/management/leadership experience in managed care setting
  • Experience in delivery and implementation of Utilization Management and Quality initiatives.

WHAT WE OFFER

A competitive and robust compensation package, including:

  • Health benefits
    • Medical: You’ll have a choice of medical plans, including options from Kaiser and Blue Shield of California. Employee-only coverage in the HMO plans is currently available at no cost and dependent coverage is heavily subsidized by SFHP.
    • Dental: You’ll have a choice of a basic dental plan or an enhanced dental plan which includes orthodontic coverage.
    • Vision: Employee vision care coverage is available through Vision Service Plan (VSP).
  • Retirement – Employer-matched CalPERS Pension and 401(a) plans, 457 Plan
  • Time off – 23 days of Paid Time Off (PTO) and 13 paid holidays
  • Professional development: Opportunities for tuition reimbursement, professional license/membership.
  • An opportunity to work in a vibrant atmosphere with the most amazingly talented people who are shaping the future of healthcare!
  • The chance to make a difference in the lives of many San Francisco residents!

ABOUT US

Established in 1997, San Francisco Health Plan (SFHP) is an award winning, managed care health plan whose mission is to provide affordable health care coverage to the underserved low and moderate-income residents in San Francisco county. SFHP is chosen by eight out of every ten San Francisco Medi-Cal managed care enrollees and its 135,000+ members have access to a full spectrum of medical services including preventive care, specialty care, hospitalization, prescription drugs, and family planning services. SFHP was designed by and for the residents it serves and takes great pride in its ability to accommodate a diverse population that includes young adults, seniors, and people with disabilities.

San Francisco Health Plan is proud to be an equal opportunity employer. We are committed to a work environment that supports and respects all individuals and in which our processes are applied without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic origin, military service status, citizenship, or other protected characteristics.

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

San Francisco Health Plan is an E-Verify participating employer.