Shire Jobs

PRINCIPAL RESPONSIBILITIES:

The Chief Medical Officer is an integral member of the executive team and is responsible for building a strong vision, sense of commitment and competence within and between the clinical teams and with other departments of the health plan.

The Chief Medical Officer will be responsible for establishing and maintaining excellent relationships with the provider community. This includes the willingness to meet often with providers to address any issues and to build and maintain provider trust and loyalty.

The Chief Medical Officer is responsible for leadership of the Medical Management programs of the Alameda Alliance for Health (the Alliance), including quality and accreditation, utilization management, pharmacy services, credentialing, case management programs and clinical policy formulation.

Together with the leadership of Medical Management Services, Quality Management, Case Management, Pharmacy, the Chief Medical Officer is responsible for the ongoing creation of structure within the these departments, including establishing systems of accountability.

Principal responsibilities include:

• Develop and implement a strategic vision and plan to deliver seamless health care services to a culturally diverse membership who traditionally lacks access to comprehensive high quality medical care in collaboration with the clinical management teams.
• Work with the Chief Executive Officer, Alliance providers, and members in the community to:
• Develop and advocate for programs and delivery systems that provide high-quality, cost-effective services.
• Build community support for the Alliance.
• Expand the visibility and influence in order to affect health care policy at the county and state level.
• Develops, implements, and evaluates programs within Health Services including:
  • Utilization Management
  • Quality Management Improvement Activities including HEDIS improvement strategies.
  • Population Health management activities including initiative/mandates intended to enhance care delivery aligned with Triple Aim (improve quality, lower cost and support member and provider satisfaction)
  • Reports to the Governing Board on progress on the programs.
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• Consult in the development and implementation of new products and benefits.
• Assist in promoting the use of web technology (e.g. Web, PDA, EPR, etc.) by physicians and consumers in conjunction with the Alliance's strategies.
• Monitor physician compliance with contractual responsibilities in conjunction with the Network Management department, particularly in the areas of utilization review and quality management.
• Encourage providers to effectively manage the delivery of health care and Alliance members to use the delivery network effectively and appropriately.
• Serve as key intermediary between the Alliance and providers, maintain effective and consistent communications and professional relationships with providers, and represent the concerns and recommendations of physicians.
• Assist in recruitment and orientation of participating Alliance providers.
• Provide clinical consultation and oversight of the Alliance's clinical programs.
• Perform continuing evaluation and modification of the Alliance's programs to improve the quality and efficiency of health care delivery.
• Assist in the development of first-rate, collaborative clinical management teams and support inter-departmental communication, cooperation, and collaboration.
• Develop utilization management criteria and clinical protocols for the Alliance, analyze trends, and recommend policy, program, and practice changes designed to achieve outstanding utilization results.
• Assist in the development of an overall strategic direction for clinical, disease management and continuous quality improvement programs.
• Provide oversight of member communication that has clinical information.
• Ensure that medical decisions are rendered by qualified medical personnel, unhindered by fiscal or administrative management.
• Ensure that medical care meets standards for acceptable medical care and establish comprehensive, clear standards of clinical care that identify desirable, observable characteristics of care, based on evidence-based, community, state and national practice guidelines.
• Develop, implement, and monitor the health plan's quality management plans, including monitoring the quality of Medical Services provided to members, credentialing, peer review, grievance monitoring and consumer satisfaction.
• Serve as chair of the Quality Improvement and Health Equity Committee, Peer Review, Credentialing and Pharmacy and Therapeutics committees and work with ad hoc physician and provider committees.
• Participate in the grievance and external medical review processes and resolve medically related and potential quality related grievances and issues, authorizations, appeals decisions and denials.
• Responsible for NCQA accreditation readiness with regard to Quality, Population Health, and Utilization Management standards.
• Directs and monitors Behavioral Health activities.
• Directs and monitors Health Services operations and programs designed to support Health Services activities including: utilization management, quality management and improvement activities, and population health.
• Directs and monitors non-specialty behavioral health services delivery to Alameda Alliance for Health (AAH) members.
• Establishes and maintains strong strategic partnerships with clinical leaders from AAH's contracted Medical Groups
  • Provide clinical leadership in the oversight of delegated IPAs and delegated medical groups/clinics' compliance with contractual responsibilities in delegated activities including utilization, care management and quality management activities.
  • Provides clinical leadership to AAH Facility Site Review (FSR) team and facility site and medical record reviews.

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``` - Perform other duties and special projects as assigned.

External Activities

• Participates in LICOHS CMO meetings and activities.
• Participates in DHCS Medical Directors meetings/workgroups.
• Attends and participates in relevant trade organization meetings through ACAP, LHPC

Works with DHCS and other regulators to facilitate compliance with regulatory requirements for the Plan and AAH providers. Other activities as needed to keep the Plan running smoothly and efficiently.

ESSENTIAL FUNCTIONS OF THE JOB

Perform administrative duties, medical management and concurrent review including managing staff, oversee special projects in support of efficient and effective plan operations and improved health care delivery within the plan network.

Oversee provider credentialing and establish and maintain provider and community relationships.

Oversee medical management, including utilization management and concurrent review.

Oversee clinical program deliverables including the quality program.

Perform writing, reporting, administration, research, and analysis.

Comply with the organization's Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.

Champion and communicate the AAH mission and vision, both internally and externally. Provide effective strategic and tactical leadership.

Act with integrity, honesty and fairness, remaining mindful of the duty of trust AAH has to it employees, and to its providers, employers and members.

Identify prospective business process improvements. Develop, impl