Medical Director - Denver Health Medical Plan *must reside in Colorado*

Denver Health; Broadway; On-site; USD 299,000 - 495,000; Full time

Job summary

An established industry player is seeking a dedicated Medical Director to lead its Managed Care initiatives. This pivotal role involves overseeing medical management activities, improving member care, and ensuring compliance with regulatory standards. The ideal candidate will have extensive clinical and managed care experience, with a focus on quality improvement and collaboration with clinical providers. Join a mission-driven organization that prioritizes community health and offers outstanding benefits, including generous paid time off and professional development opportunities. This is a unique chance to make a significant impact in the healthcare landscape.

Benefits

27 paid days off per year

Immediate retirement plan contribution up to 9.5%

Generous medical plans

Free RTD EcoPass

On-site employee fitness center

Childcare discount programs

Tuition reimbursement

Professional clinical advancement program

Public Service Loan Forgiveness eligibility

Education & development opportunities

Qualifications

• 10+ years of clinical practice and managed care experience required.
• Knowledge of NCQA and managed care regulations preferred.

Responsibilities

• Develop and implement medical management activities for members.
• Provide clinical oversight for Pharmacy and Quality Management.

Skills

Clinical practice experience

Managed care experience

Quality improvement knowledge

Communication skills

Healthcare financing understanding

Education

Doctorate Degree

Tools

Computer skills

Job description

We are recruiting for a motivated Medical Director - Denver Health Medical Plan *must reside in Colorado* to join our team!

We are here for life's journey.
Where is your life journey taking you?

Being the heartbeat of Denver means our heart reflects something bigger than ourselves, something that connects us all:

Humanity in action, Triumph in hardship, Transformation in health.

Department

Managed Care Administration

Job Summary

The Medical Director of Managed Care functions as the Denver Health Medical Plan's Chief Medical Officer and is responsible for the development, implementation and evaluation of medical management activities carried out by Managed Care on behalf of its members. The overarching goals of these activities are to fulfill regulatory requirements, improve member care and outcomes, reduce unnecessary health care expenses, and insure that clinical services are provided in a manner consistent with each health plan's benefits.


Essential Functions:

• Supports relevant functions of the Pharmacy and Quality Improvement & Accreditation Departments and utilization, care, and disease management processes. (5%)
• Serves as a liaison to the clinical departments at Denver Health. Responsible for educating Denver Health's clinical providers about the Medical Plan's benefit plans and management resources, including how to refer members in need of those resources, request prior authorization approval, and how to collaborate with Managed Care to meet our shared goals and objectives. (5%)
• Supports Managed Care's medical management initiatives with the clinical activities in Denver Health's inpatient and outpatient settings. (5%)
• The Medical Director may serve on various Denver Health Committees. (5%)
• Provides clinical oversight and support for the Medical Management areas of: Pharmacy, Quality Management and UM/CM/DM. (5%)
• Engages with Denver Health and external providers to address practice patterns to ensure member care and quality initiatives. (5%)
• For each line of business in the Medical Plan, develops and monitors annual cost and utilization targets for key medical service areas such as: pharmacy, admissions, LOS, re-admissions, ED utilization. Implements initiatives to improve areas that do not meet established targets. (5%)
• Evaluates utilization, national and local trends and identifies interventions to optimize the utilization of resources, control cost and delivery of quality health care services. (5%)
• Monitors medical costs outside of Denver Health. Identify areas of opportunities to bring more services into Denver Health. (5%)
• Provides clinical direction to the Quality Management, Pharmacy and Medical Management Departments in the development of clinical initiatives and programs for the annual Quality Improvement Work Plan by line of business. (5%)
• Responsible for supporting the Quality Improvement Program for Denver Health Medical Plan and Denver Health Medicaid Choice. (5%)
• Responsible for analyzing HEDIS results for all lines of business and reviewing Quality Improvement measures and others areas to identify clinical measures for planned interventions. (5%)
• Oversees the process of reviewing quality of care concerns and remediating identified quality of care problems. (5%)
• Remains abreast of applicable contractual and regulatory quality clinical requirements for Medicaid/CHP, Medicare, Commercial and Exchange lines of business. (5%)
• Works with the Quality Management, Pharmacy and Medical Management Departments on the implementation of processes, policies and programs to meet all requirements. (5%)
• Ensures that all contractual, regulatory and accreditation requirements are met by Medical Management functional areas. Participate in on-site audits. (5%)
• Represents the Plan in external regulatory audits, HEDIS audits, and accreditation site reviews for medical management. (5%)
• Meets as needed with applicable regulatory agencies and contractors to clarify requirements, resolve issues, develop, and collaborate on programs to meet such requirements. (5%)
• Promotes the development of innovative programs that meet members' healthcare needs, promote disease management, and improve behavioral health and wellness. (5%)
• Develops and implements plans to improve employee engagement in collaboration with department directors and their managers. (5%)

Education:

• Doctorate Degree required

Work Experience:

• 10+ years Clinical practice experience required and
• Three years of managed care experience (either in a medical group or health plan) in utilization management, population health, disease management, health care quality improvement programs, or clinical guideline development and implementation required or
• Three years managerial experience required

Licenses:

• MD-Physician - State Medical Board required

Knowledge, Skills and Abilities:

• Demonstrates an understanding of quality improvement, population health, disease management, utilization, case and disease management programs and healthcare financing and costs.
• Ability to develop collaborative relationships with internal departments and providers at Denver Health as well as all external providers and partners.
• Must have effective oral and written communications skills.
• Knowledge of NCQA and managed care regulations/requirements for HMO, Medicaid and Medicare Advantage preferred.
• Experience working in an outsourced UM/CM/DM environment preferred.
• Computer skills required.

Shift

Days (United States of America)

Work Type

Regular

Salary

$299,700.00 - $494,500.00 / yr

Benefits

• Outstanding benefits including up to 27 paid days off per year, immediate retirement plan employer contribution up to 9.5%, and generous medical plans

• Free RTD EcoPass (public transportation)

• On-site employee fitness center and wellness classes

• Childcare discount programs & exclusive perks on large brands, travel, and more

• Tuition reimbursement & assistance

• Education & development opportunities including career pathways and coaching

• Professional clinical advancement program & shared governance

• Public Service Loan Forgiveness (PSLF) eligible employer+ free student loan coaching and assistance navigating the PSLF program

• National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer

Our Values

• Respect

• Belonging

• Accountability

• Transparency

All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made.

Denver Health is an integrated, high-quality academic health care system considered a model for the nation that includes a Level I Trauma Center, a 555-bed acute care medical center, Denver's 911 emergency medical response system, 10 family health centers, 19 school-based health centers, Rocky Mountain Poison & Drug Safety, a Public Health Institute, an HMO and The Denver Health Foundation.

As Colorado's primary, and essential, safety-net institution, Denver Health is a mission-driven organization that has provided billions in uncompensated care for the uninsured. Denver Health is viewed as an Anchor Institution for the community, focusing on hiring and purchasing locally as applicable, serving as a pillar for community needs, and caring for more than 185,000 individuals and 67,000 children a year.

Located near downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.

Denver Health is an equal opportunity employer (EOE). We value the unique ideas, talents and contributions reflective of the needs of our community.

Applicants will be considered until the position is filled.