The Medical Director will carry out responsibilities as defined by the California Knox-Keene Health Care Service Plan Act, as well as applicable regulations and Health and Safety Code sections for Ventura County Health Care Plan (VCHCP), a Department of Managed Health Care (DMHC) licensed Commercial HMO. The Medical Director operates as part of a team of 65 with no direct reports, and a $90 million dollar budget. In accordance with the National Committee on Quality Assurance (NCQA), the Medical Director for VCHCP is responsible for the leadership and direction in planning, and coordinating medical reviewer staff to ensure appropriate, professional, and cost-conscious inpatient and outpatient health care, assuring the quality of care provided to the members of the health plan by institutions, physicians, and allied professionals. As a licensed health plan, VCHCP is required to be compliant with all regulatory requirements of any other large insurance plan.
Looking for: A collegial, mission-driven physician leader with extensive experience in licensed HMO operations and a strong grasp of regulatory frameworks. The successful candidate will be adept at navigating change in the healthcare landscape, will have experience chairing committees and guiding medical services through operational transitions, and will prioritize member safety, quality, and regulatory compliance in decision making.
Core Responsibilities:
Provides overall direction, guidance, and control for the medical components of VCHCP's services to ensure appropriate, professional, and cost-conscious health care.
Develops and interprets medical policies. Coordinates and communicates matters of VCHCP medical policy with the Health Care Agency Director and Insurance Administrator, Utilization Management staff and Quality Assurance Staff.
Participates, as a member of the Senior Management Team, in developing goals, plans and policies for the organization, assuring that the medical decisions will not be unduly influenced by fiscal and administrative management.
Ensures that comprehensive medical benefits are effectively developed and administered for VCHCP patients.
Conducts provider credentialing and Re-Credentialing. Develops practice profile indicators. Member of Credentialing, Quality Assurance {QA) and Peer Review Committees. Presents to Standing Committee identified provider quality concerns. Implements any Committee disciplinary actions, including any remedial and punitive measures.
Reviews results of facility site surveys performed by Provider Services Administrator. Communicates with providers deficiencies identified in practice site surveys and monitors corrective action plans submitted by providers.
Manages and controls inpatient utilization and outpatient referrals with attention to quality and cost-effective methods. Delegates performance of routine QA/UR activities to the QA/UR Nurses based upon guidelines approved by the medical director and Plan Committee.
Provides or arranges timely review and response to requests for VCHCP services which require physician authorization {i.e., emergency hospital admissions, elective admissions, elective surgical procedures, referrals, tests, medication approvals requiring authorization.)
Develops utilization management standards and guidelines for approval by the Utilization Management Committee consistent with sound clinical principles and processes and with current medical and scientific information.
Communicates standards and guidelines to VCHCP providers.
Member of Utilization Management, Quality Assurance, Pharmacy and Therapeutics and Standing Committees.
Provides a timely review and response to Member complaints that involve denial of services or concerns related to medical quality.
Develops and maintains professional and effective working relationships with Plan providers to optimize organizational growth and profitability. Responds to provider inquiries regarding Plan decisions, clarifies related matters as appropriate.
Develops and implements Quality Assurance Plan. Develops Quality Assurance Indicators. Member of QA, Pharmacy & Therapeutics, and Standing Committees.
Defines and monitors compliance with quality management standards and protocols in collaboration with Network Providers and the VCHCP QA Committee.
Approves agenda and minutes for VCHCP QA and Utilization Management Committees. Ensures that Committee activities follow the guidelines set forth in the QA and UR plans and that Committee actions and assignments are completed in a timely manner as directed. Ensures that QA/Utilization Management Committee meetings are well attended by physicians of sufficient background and knowledge in the treatment of the medical conditions under discussion.
Reviews all Potential Quality Issues {PQl's) identified by the Plan and initiates the request for information {including assessment by other QA entities) needed to assess the PQI. Rates each PQI for seriousness of the incident and reports the results to the QA Committee.
Refers issues of provider quality concerns to the Plan's Credentials Committee and makes recommendations as to actions to be taken by the Plan.
Implements disciplinary actions recommended by the Credentials Committee as defined by the Plan's Policy.
Ensures that any actions taken by the Plan against a provider for medical quality issues will be reported to the appropriate oversight bodies.
Participates in the recruitment, interviewing, selection, and performance appraisal of VCHCP providers.
Represents the Plan in a liaison role with other agencies and individuals as apparent or assigned.
Provides consultation to VCHCP management and staff as requested.
Attends the meetings of the Standing Committee, the Plan's oversight committee. Presents the Plan's Utilization and Quality Reports and relays concerns identified by the Plan's Staff.
Participates in Plan inter-rater reviews.
Promotes Health Equity, Population Health Management, and quality standards.
Performs related duties as assigned.
Doctor of Medicine or Osteopathy Degree,
Current physician license to practice medicine in the State of California without restrictions
Completed residency in primary care field of specialization (i.e. Family Practice, Internal Medicine, Pediatrics or Obstetrics/Gynecology).
Must be Board certified in California
Thorough knowledge of the current principles and techniques of diagnosis and treatment
Experience with managed care
Experience and current knowledge of Quality Assurance, Utilization Review, Peer Review and programs
At least three (3) years of direct patient care medical practice experience
At least three (3) years of administrative experience
The Ventura County Health Care Plan (VCHCP) is a service oriented, County sponsored Health Maintenance Organization (HMO) that offers an extensive range of benefits and low out-of-pocket expenses. Established during the 1993-94 fiscal year, the Ventura County Health Care Plan was developed as a practical and cost effective option for providing health care services to County employees and their covered dependents.
