Associate Medical Director (Part Time/20 Hours Per Week)

Job SummaryResponsible for contributing to the development, maintenance, oversight and implementation of medical management policies, procedures, and guidelines applicable to the facilitation of the provision of quality, cost effective care for the enrolled patient population of Community Health Plan of Washington (CHPW). Working with the Health Plan Medical Directors and the Clinical Services Division, oversees medical care for products and services and oversees the health care needs of the membership. Is accountable for and provides professional leadership and direction to the Utilization Management, Quality Management, and Care Management functions.

Works collaboratively with other plan functions that interface with Clinical Services. Assists in short and long range program planning, quality improvement and external relationships. Works within Clinical Services and with other departments for support, assistance and direction in overall medical management effectiveness.Essential Functions* Partners with the Chief Medical Officer (CMO), Health Plan Medical Directors and Directors of Delegated Healthcare Services, Quality, Pharmacy and Medical Management Program.* Partners with the Clinical Services teams to develop and effectively implement programs.* Partners with the CMO and the Healthcare Economics and Finance departments in the development and production of utilization and cost reports, data analysis and dissemination of these data and reports to key stakeholders, internal and external to CHPW, as needed.* Provides clinical guidance for CHPW's utilization, pharmacy, and case management activities, claims reviews, and medical necessity decisions.* Is jointly responsible for maintenance of routine care and screening guidelines, disease management guidelines, and authorization and referral coverage criteria as per regulatory requirements with the Health Plan Medical Directors.* Assists in the development and updating of prior authorization lists and criteria.* Researches, evaluates, and approves new technology and based on clinical evidence, makes determinations whether services are experimental and investigational.* Assists in the development, reporting, monitoring, and analysis of department measures that are linked to organizational goals.* Actively uses and supports quality improvement principles and methods in an effort to improve inter- and intra-departmental processes.

Participates on quality improvement project teams as a member, leader and/or sponsor.* Reviews and renders determinations on denials of coverage based on medical necessity using defined criteria.* Is responsible for ensuring that clinical decisions regarding individual enrollees made by health plan staff are consistent with established benefit coverage, clinical guidelines, and standards of practice.* Discusses specific cases with providers as needed.* Helps define and support case management efforts and interacts with providers to improve outcomes for complex patients.* Serves on various case management rounds as needed (including Medicare Dual Special Needs Population, Neonatal Intensive Care, Integrated Managed Care, and Case Management)* Collaborates with the case managers in making out-of-contract benefit exceptions when appropriate.* Reviews and resolves member quality-of-care and provider complaints as needed.* Participates in Credentialing Committee* Participates in the Second Level Appeal Committee meetings as needed.* Provides medical information as it relates to policy decisions for member appeals.* Participates in post payment review activities as needed.* Assures plan conformance with legal and regulatory requirements.* Supports NCQA qualification and other monitoring activities and in HCA TeaMonitor and CMS audits. Prepares for site visits and responds to accrediting and regulatory agency feedback.* Participates in the retrospective review and analysis of Plan performance from summary data of paid claims, encounters, authorization logs, compliant and grievance logs and other sources.* Achieves and maintains benchmarked utilization and cost management (UM) goals and clinical quality improvement (QI) objectives.* Participates in risk management, claim adjudication, pharmacy utilization management, catastrophic case review, outreach programs, HEDIS, CAHPS and STAR reporting.* Monitors member and provider satisfaction survey results and implements changes as needed to increase satisfaction and assure that satisfactory relationships are maintained between network and plan participants.* Exempt - Employees are expected to report to work as scheduled, participate in all assigned meetings, and meet established performance and accountability standards.* Other duties as assigned. Essential functions listed are not necessarily exhaustive and may be revised by the employer, at its sole discretion.QualificationsEducation* Medical degree (MD or DO) and licensed to practice medicine in Washington State.* Licensure must be current and unrestricted.* Completion of a residency program in a primary care specialty, with Board Certification required.* Additional business-related degrees or training strongly preferred.* Demonstrated continuing education to remain current in medical and management areasExperience* Minimum of three years of clinical practice required.* Minimum of one year of leadership experience in a managed care system.* Experience with community or migrant health centers preferred.* Experience in the development and implementation of effective health care policy, particularly in the areas of quality monitoring, medical appropriateness, and utilization of health care services preferred.Employment Eligibility* Complete and successfully pass a criminal background check* Has not been sanctioned or excluded from participation in federal or state healthcare programs by a federal or state law enforcement, regulatory, or licensing agencyKnowledge, Skills, and Abilities* Demonstrated high proficiency and expertise in clinical work and cost-effective health care.* Knowledge of the various components of managed care (quality improvement, disease management, population management, utilization management, case management and pharmacy management).* Highly skilled and knowledgeable in the development and implementation of health care policy, particularly in the areas of quality, medical appropriateness, and utilization of health care services.* Knowledge of HEDIS, CAHPS, NCQA, JCAHO, and other standardized certifications and quality measures.* Knowledge of regulatory agencies and requirements.* Able and willing to travel throughout the state to become familiar with participating health centers.* Must possess excellent communications skills to interface with providers, staff, and management.* Able to manage multiple priorities and deadlines in an expedient and decisive manner.* Able to manage difficult peer situations arising from medical care review.* Appreciation of cultural diversity and sensitivity towards target populations.Compensation and Benefits:The position is FLSA Exempt and is not eligible for overtime.

Based on market data, this position grade is 103 (see full range below) and has a 15% annual incentive target based on company, department, and individual performance goals.CHPW offers the following benefits for Full and Part-time employees and their dependents:* Medical, Prescription, Dental, and Vision* Telehealth app* Flexible Spending Accounts, Health Savings Accounts* Basic Life AD&D, Short and Long-Term Disability* Voluntary Life, Critical Care, and Long-Term Care Insurance* 401(k) Retirement and generous employer match* Employee Assistance Program and Mental Fitness app* Financial Coaching, Identity Theft Protection* Time off including PTO accrual starting at 17 days per year.* 40 hours Community Service volunteer time* 10 standard holidays, 2 floating holidays* Compassion time off, jury dutySENSORY/PHYSICAL/MENTAL REQUIREMENTSSensory*:* Speaking, hearing, near vision, far vision,.Physical*:* Extended periods of sitting, computer use, talking and possibly standing* Simple grasp, firm grasp, fine manipulation, pinch, finger dexterity, supination/pronation, wrist flexion* Frequent torso/back static position; occasional stooping, bending and twistingMental:* Must have the ability to learn and prioritize multiple tasks within the scope and guidelines of the position and its applicable licensure requirements, many requiring extremely complex cognitive capabilities. Must be able to manage conflict, communicate effectively and meet time-sensitive deadlines.WORK ENVIRONMENTOffice environment with frequent environmental exposure to low-grade radiation from computer monitors; fast paced with frequent interruptions.PROTECTED HEALTH INFORMATION (PHI) ACCESSAll information (written, verbal, electronic, etc.) that an employee encounters while working at CHPW is considered confidential. CHPW employees may encounter protected health information in the regular course of their work at and for CHPW.

This position may be exposed to and required to deal with highly confidential and sensitive material and must adhere to CHPW policies, guidelines, and all applicable laws and regulations at all times.* Candidates whose disabilities make them unable to meet these requirements are considered fully qualified if they can perform the essential functions of the job with reasonable accommodation.This job description is intended to describe the general content and the requirements for satisfactory performance in this position. It is not to be construed as an exhaustive statement of the duties, responsibilities or requirements of this position.Community Health Plan of Washington is an equal opportunity employer committed to a diverse and inclusive workforce. All qualified applicants will receive consideration for employment without regard to any actual or perceived protected characteristic or other unlawful consideration.