Senior Medical Director

PacificSource is anything but a typical health insurance company. Founded in 1933, we’re an independent, not-for-profit organization that puts our members, and their communities first—across Idaho, Oregon, Montana, and Washington. It's our 1,700 employees who make it happen: promoting health equity and partnering with providers to deliver better access to optimal, affordable care. So yes, with PacificSource, you get to do great things. In our effort to put members first—more than 500,000 of them—initiative, commitment, and hard work are supported and rewarded with excellent benefits, competitive wages, and opportunities for personal growth and advancement. Benefits: Flexible telecommute policy, medical, vision, and dental insurance, incentive program, paid time off and holidays, 401(k) plan, volunteer opportunities, tuition reimbursement and training, life insurance, and options such as a flexible spending account. We love our common purpose. Empowerment, flexibility, and sharing success make for a great place to work. Here’s what else we feel good about: A mission with a real sense of shared values Competitive wages and outstanding benefits, including telecommuting Opportunities for learning development and career advancement Organizational leadership style rooted in servant and transformational leadership A commitment to support the communities we serve A belief in the importance of work-life balance PacificSource is an equal opportunity employer and a company that loves helping people. We work with our employees to understand their goals, and provide training, individual development, and career advancement opportunities to help them achieve just that. In 2021 alone we had 240 internal promotions! Top Workplace 2022 for Idaho | Idaho Press Top Workplace 2022 for Oregon and SW Washington | The Oregonian #4 Healthiest Employer of Oregon 2021 | Portland Business Journal Healthy Worksite 2021 | Design Coalition in Montana PacificSource is an equal opportunity employer. Click here to review our AAP Policy Statement. If you have questions about working at PacificSource or need help with your application, please email HR@PacificSource.com. Looking for a way to make an impact and help people? Join PacificSource and help our members access quality, affordable care! PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age. Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths. Position Overview: The Senior Medical Director is an operational role that manages internal operations of assigned departments, facilitates, coordinates, and operates the clinical enterprise with interfaces with assigned medical directors, and the VPs in line authority of the CMO. In addition, the Senior Medical Director role interfaces with health services project management personnel and directors inside and outside of the department in order to carry out the initiatives of the strategic plan and CMO. The Senior Medical Director may interface with appropriate governmental and regulatory agencies to influence, understand, and implement policy. Provide clinical and operational expertise for physical and behavioral health care, case, risk, network, and utilization management, as well as health promotion, disease management, pharmacy review, grievance and appeals, quality incentive programs, and revenue cycle management. The Senior Medical Director is expected to actively engage with the provider community in support of PacificSource’s strategic and operational goals. Essential Responsibilities: Closely assist the Chief Medical Officer (CMO) with providers, clients, agents, PacificSource management, board, and other functions or committees. Coordinate efforts of the PacificSource Medical Directors and their respective administrative counterparts and co-workers. Actively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy. Actively participate as a key team member in Manager/Supervisor meetings including the Provider Network/Health Services Directors Team, convened by CMO. Collaborate with all other PacificSource Medical Directors to establish guidelines, policies, criteria and procedures for review and determination related to clinical practices, claims, care coordination, reimbursement, provider credentialing, and quality management. Oversee the development of systems of care with providers for the management of appropriate care and case management related to acute, catastrophic, and long term cases. Within the clinical care domain, manage all aspects of data and analytics, informatics and IT people and processes that use IT applications to deliver actionable analytics to provider partners to achieve lower-cost care with better quality and greater customer satisfaction. Develop and monitor all IT Plan of Record activities related to the clinical/medical director enterprise. Lead Cost Containment Committees, work to include anticipation of trends impacting global budget, and proactively address those trends in line with Triple Aim goals. Manage internal operations and participate in activities related to the cost of care and cost and use functions with certain defined Provider Partners and in Coordinated Care Organization (CCO) Special Operations Committees. Provide leadership in decision making for inclusion and integration or continuation of new clinical services within Health Services e.g. successful projects funded by Transformational Resources or non-traditional services that will help achieve the Triple Aim. Lead the work of employing process improvement techniques to analyze, identify, and implement changes to workflow, staff, and organizational structure that improve operational efficiency and effectiveness in the areas of authority of the Senior Medical Director. Utilize visual boards and daily huddles to monitor key performance indicators and identify improvement opportunities; Develop annual department budgets. Monitor spending versus the planned budget throughout the year and take corrective action where needed. Review pre-authorizations, claims, and other cases involving pre- or post-service requests for coverage. Conduct other utilization review activities (e.g. lengths of stay, appropriateness of service, intensity of service, medical necessity, and experimental/investigational services) on a prospective, concurrent, or retrospective basis. Provide expertise and medical interpretation with respect to claims adjudication, underwriting, contract language, disputes and appeals, policy drafts, and care management issues. Work with the Chair Quality Assurance Utilization Management and Pharmacy and Therapeutics Committees as needed. Prepare agendas, collaborate with the committee, research of topics presented to the committee, and follow through on committee actions. Review and manage appeals and grievances. Lend expertise to the preparation of cases for appeals, presentation, or further external review. Assist in reviewing Pharmacy denials and redeterminations. Assist with the research of new technologies, new medications, and other evolving healthcare products and services to help determine a standard of care and standard of coverage. Assist with drafting and revising policies relating to such issues. Provide visibility and maintain positive physician relationships as a representative of PacificSource in local and regional medical community. Provide clinical expertise to the Quality Department, including Medicaid Incentive Measures, HEDIS Programs, and Performance Improvement Projects. With the Medical Director of Medicaid, interface with the Oregon Health Authority to influence, track, and implement Oregon Health Plan clinical policy; including active participation in relevant committee work e.g. Quality Health Outcome Committee. Responsible for hiring, staff development, coaching, performance reviews, corrective actions, and termination of employees. Provide feedback to direct reports including regular one-on-ones and performance evaluations. Supporting Responsibilities: Coordinate business activities by maintaining collaborative partnerships with key departments. Meet department and company performance and attendance expectations. Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information. Perform other duties as assigned. Work Experience: MD or DO. Five to seven years as an Assistant Medical Director or Medical Officer of a health insurance plan strongly preferred. Experience in an integrated healthcare system a plus. Significant senior management policy and decision-making experience, including developing and implementing management best practices required. Education, Certificates, Licenses: Unrestricted license to practice medicine by the Oregon State Board of Medical Examiners. Doctor of Medicine degree required. Must be able to obtain license to practice in states where PacificSource operates. Knowledge: Comprehensive knowledge of business principles and techniques of administration, organization, and management to include an in-depth understanding of the key business issues that exist in the healthcare industry. These include but are not limited to: knowledge of strategic and operational planning, healthcare economics, personnel administration, federal health reform laws, financial and cost analysis, trends in the healthcare industry, and delivery system transformation including medical home initiatives, business process improvements, analysis and redesign. Excellent verbal and written communication skills, ability to read, analyze and interpret documents, schedules, reports, budgets and correspondence. The ability to develop presentations and reports as well as effectively present information and respond to questions from a variety of groups. Proficient in the use and implementation of the following tools and concepts across all teams within scope of accountability: training, strategy deployment, standard work, visual management, daily improvement, standard follow-up and team development. Strong research, analytical, organizational, and interpretative skills. Excellent understanding of all areas of medical conditions, treatment, and care. Possesses the ability to foresee changes in treatment patterns and implement internal systems as needed. Excellent understanding of the insurance industry and risk factors and how they relate to the PacificSource organization. The ability to identify, create, analyze, and implement innovative cost containment procedures. Excellent negotiating skills. Pro-active in the application of new medical systems and procedures. Expertise in quality assurance and utilization review. Basic computer skills preferred. Competencies Building Trust Building a Successful Team Aligning Performance for Success Building Partnerships Customer Focus Continuous Improvement Decision Making Facilitating Change Leveraging Diversity Driving for Results Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 25% of the time. Our Values We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business: We are committed to doing the right thing. We are one team working toward a common goal. We are each responsible for customer service. We practice open communication at all levels of the company to foster individual, team and company growth. We actively participate in efforts to improve our many communities-internally and externally. We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community. We encourage creativity, innovation, and the pursuit of excellence. Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively. Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.