Senior Medical Director Population Health

Chief Medical Director - Population HealthCalifornia Coordinated Regional Care (CRC)Hybrid: Los Angeles, California and Orange County CaliforniaWe are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care. We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives. Through collaboration, we strive to provide all our patients and IPA medical group members with the quality, affordable healthcare they need and deserve.The Chief Medical Director - Population Health provides clinical leadership, direction, and planning for the company's contracted dual risk relationships attributed to PMH California hospitals, contracted downstream hospitals, tertiary/quaternary centers of excellence and community hospitals to achieve the Quadruple AIM. This role is responsible for the development and oversight of a wide variety of complex care service performance improvement programs, quality, coding accuracy, medical and related activities for the Coordinated Regional Care (CRC) Group and its California contracted IPAs for patients served under value-based and risk contracts with payors and integrating these programs in conjunction with our contracted risk partner IPAs (currently: GCMG, BVMG and AIPA) lines of business, contracted healthplans and CalAIM programs serving dual risk patients. The Chief Medical Director - Population Health develops new innovative integrated care management, chronic care, and social driver of health diversion programs to better manage the risk population under management. This executive serves as the driver, liaison and clinical resource on matters pertaining to quality and clinical activities and oversees the Population Health, Quality, Chronic Care Management and Case Management/Discharge Planning initiatives for the Dual Risk patients under management of CRC on behalf of the PMH California Hospitals. The Chief Medical Director - Population Health is committed to the mission of quality, safety, service, and improvement of patient clinical outcomes and cost-effectiveness and, in conjunction with the contracted IPAs and MSOs Medical Directors, for transforming the disjointed broken health care system into an integrated delivery system capable of successfully assuming and managing global risk and delegated contracts from payors. Additionally, he or she is the leader in promoting physician performance in these areas which includes engaging physicians and helping guide the embracement of change to bring value-based care success to each facility. Ultimately, the successful Chief Medical Director - Population Health will be a change agent, champion of innovation and be able to understand roadblocks and look for new ways to bring process improvements and new programs to reduce re-admissions, avoidable admissions and engage chronically ill patients to take charge of their health to enable them to live their best possible life.Job Responsibilities/DutiesLeads and develops California Dual Risk IPA Population Health Medical Directors, Director of Care Management and Population Health Manager and is responsible for the direction of quality, clinical and operations staff to coordinate and/or manage care provided to patients in their local IPAs. Directly supervise medical directors and others as appropriate to develop and improve Chronic Care Programs including but not limited to Avoidable Chest Pain Admissions, COPD, CHF, Diabetes, TCM/Coleman LOS and Readmission Programs as well as HEDIS, STARs, Hierarchical Condition Coding initiatives and other quality-based measures so that our dual risk IPA/MSO partners and health systems are in the top tier for these scores.Develops, reviews, updates, seeks consultation and collaboration, and implements quality, pay for performance, correct coding and medical policies and processes that promote and ensure delivery of appropriate clinical care at the highest level of quality and cost efficiency with a focus on behavioral health and social determinants of health integration in the contracted California based dual risk IPA partners and their respective MSO partners for patients served under value-based and dual risk contracts with payors.Ensures the California Dual Risk population health quality, correct coding, and clinical teams (including external contracted parties) adhere to consistent, effective and aggressive quality, utilization, care management and discharge planning processes and procedures while assuring the correct charting and coding of services provided and there is measurable improvement in patient satisfaction, and outcomes. Chief Medical Director - Population Health is responsible for the hospital, MSO, and IPA physician leader relationships and for successful integration of population management and chronic care programs within the health systems' case management, hospitalist emergency department and other clinical programs to improve the clinical performance and measures of the entire integrated delivery system.Intervenes with medical directors, individual physicians or clinical staff who are contracted with company IPAs when there are higher level of care, performance, or behavioral issues.Leads the development of clinical policies, programs, and process flow development in California as it relates to patient utilization and care management activities, including review and management of inpatient and outpatient authorizations, denials, peer to peer meetings, denial upholds and participating in Interdisciplinary Team and inpatient rounds for patients served under value-based and risk contracts with payors.Develops close and productive working relationships with CMOs and other clinical leaders of key payors, including State and local government payors, to develop state of the art programs to serve populations under management and to influence policy and program development for those populations.Partners with leadership to develop Medical Director and other key physician contracts in collaboration with Finance, Legal and Human Resources departments.Collaborates with leadership to standardize and integrate quality, correct coding and clinical programs where appropriate in California.Participates in strategic planning and assists in constructing, meeting, and exceeding appropriate system level quality, appropriate charting/coding, clinical goals and targets.Assists in negotiations of value-based and risk contracts with payors particularly in matters pertaining to quality improvement, clinical guidelines, bending the cost curve, utilization management and improving patient satisfaction and outcomes.Develops and leads the implementation of clinical, social, and behavioral programs designed to assist and successfully manage patients with the most complex medical and social circumstances in the value-based and risk populations we serve and extend and integrate these programs into the practices of our health systems.Partners with quality, care managers,discharge planners, and other clinical staff to respond to and investigate adverse events and Physician concerns, including denials; then develops and implements appropriate action plans to remediate. Follows through on plans to effect change and report out the results in a timely manner.Develops state of the art quality, correct coding and cost containment systems and processes to promote the efficient and effective use of clinical resources for patients served by the CA Dual Risk contractual agreements with health plans and IPA/MSO partners under value-based and risk contracts with payors.Review data, admissions in network/out of network), HLOC utilization and reports opportunities for effectiveness. Uses information to coach and mentor physicians and clinical teams to assure effective coding, efficient throughput of inpatient hospitalizations and timely discharge planning processes. Chief Medical Director - Population Health organizes and leads the MSO, Hospitalists, IPA and Hospital teams to participates in an in and outpatient daily rounds calls which case manage the patient's stay with the applicable parties to assure timely testing, treatment and or care management planning efforts to effect efficient length of stay. Works with medical directors and hospitalists to develop care algorithms and standards of care which increases the quality of life for chronically ill patients. Assures compliance with health plan, State and Federal regulatory standards. Additional responsibilities may be assigned based on needs of the organization. This may include serving as an executive sponsor and mentor for a service line, leading a quality or correct coding initiative, participating in specialty task forces and other duties as assigned. Special projects or unique local responsibilities may also be added.QualificationsMinimum Education: Doctorate of Medicine, completion of USA accredited Residency.Minimum Experience: Minimum of three (3) years of direct clinical or acute care experience. Strong quality and care management background with at least five (5) years of executive-level experience within a health plan, IPA, health system or medical group. Strong knowledge of health plan, MSO and IPA processes, programs and operations including incentive programs such as P4P/HCC/STAR/HEDIS. Experienced with health plan guidelines/criteria including Milliman (MCG), CMS and NCQA.Req. Certification/Licensure:Current unrestricted MD or DO license in California.Active Board Certification in trained specialty, preferable in Internal Medicine, Emergency Medicine or Family Medicine

Created: 2025-01-22