Associate Medical Director-Exempt - CCHP

The Position

Why join the Contra Costa Health Services Department?

CCHP is Contra Costa's single plan Medi-Cal health plan and provides healthcare coverage to over 250,000 members, the majority of whom are Medi-Cal beneficiaries. CCHP is part of Contra Costa Health Services, which is dedicated to providing accessible, high-quality, and cost-effective healthcare to the residents of Contra Costa County. As a member of CCHP, you will contribute to an organization that prioritizes health equity, innovation, and the highest standards of patient care. By joining our team, you will be part of a dynamic and collaborative environment where your expertise will help improve the health outcomes of the community.

What you will typically be responsible for

• Providing physician oversight to Clinical Departments including but not limited to Utilization Management, Appeals and Grievances, Pharmacy, Case Management
• Reviewing and making final clinical decisions on appeals and grievances, including complex and high-risk cases, ensuring decisions are timely, well-documented, and defensible from a regulatory and clinical standpoint
• Partnering closely with utilization management nurses, pharmacists, care management, and operational leaders to support consistent, evidence-based decision-making and to resolve clinical issues that arise during daily operations
• Participating in and providing clinical expertise to key health plan committees, such as Utilization Management, Quality Improvement, and Medical Policy committees, helping to guide oversight, performance improvement, and compliance activities
• Supporting the development, review, and implementation of medical policies, clinical guidelines, and workflows to ensure alignment with current standards of care and regulatory requirements
• Conducting utilization review & making medical necessity determinations for inpatient, outpatient, and specialty services in accordance with Medi-Cal, DHCS, CMS, and CCHP policies
• Overseeing fidelity of Clinical Operations in various Clinical Departments (internal auditing of RN and Physician activity)
• Identifying opportunities for optimization in Clinical Processes (e.g. building clinical referral pathways, building synergy between payor and provider activity)

Minimum Qualifications

• Licenses Required: Possession of a valid physician license issued by the Medical Board of California, and a Board Certification in the specialty applicable for the assignment.
• Unrestricted current medical license, certification or registration in CA with DEA licensure.
• Board Certified in Internal Medicine, Family Practice, Emergency Medicine or Correctional Medicine.
• Experience: Three (3) years of full-time experience, or its equivalent, in the practice of medicine. One (1) year in a responsible administrative capacity applicable for the assignment is desirable.

Desirable Qualifications

• Strong background in managed care especially Medi-Cal, Medicare Part D, or D-SNP
• Experience in Epic Electronic Health Record
• Familiarity with regulatory requirements from DHCS, CMS, NCQA, and other oversight bodies
• Strong knowledge of utilization management principles
• Experience in Clinical Case Management, including Chronic Disease Management and inpatient facility discharge planning