General Summary

Responsible for clinical leadership, direction and oversight of the health plan's medical affairs including the QAPI Program as well as continuous measuring, monitoring and improvement of the health delivery system for plan members to help ensure that health plan members receive quality, medically necessary care that balances individual need with cost effectiveness. 

Essential Functions and Duties

Department Management
Direct Supervision of the Complex Case Management /Prenatal Case Management Supervisory staff.  

• Establish operational goals and objectives. 
• Plan, staff and manage relevant activities necessary to deliver excellent service to members conducted in a manner that assures consistent high quality service results, client satisfaction, on-target financial performance and assures   compliance with DHS contractual requirements as well as the health plan policies and procedures.
• Establish and maintain a professional, supportive, client service-oriented workplace culture with high standards of individual and team performance. 

Quality Improvement
Provide leadership and oversight of the QAPI program.  Plan, design, implement and coordinate QAPI activities.  Evaluate quality and utilization related issues:

• Oversee the development, dissemination, implementation and evaluation of clinical practice guidelines, preventive health guidelines and benefit interpretation guidelines.
• Communicate information and decisions to network practitioners and providers, and follow-up on corrective action plans implemented for issues regarding quality of care or  Member safety
• Ensure effectiveness of quality activities and allocate resources
• Supervise all of healthcare services including operational oversight responsibility.  .
• Review Member appeals and Grievances related to quality of care issues
• Chair the quality improvement committees and sub-committees and report to the Board at the quarterly meetings.
 • Demonstrate and promote the QAPI Program through communication, practice and resource allocation.
 • Achieve of organizational goals.
 • Direct involvement in QI activities to include:
  a. Identify and resolve UM/QM issues of network practitioners with IPAs and networks.
  b. Analyze statistical and quantitative data to improve health plan performance along with provider/member satisfaction Analysis of UM and QI data
  c. Examine information concerning patient outcomes, hospital admissions, healthcare provider practice patterns and identification of clinical outliers.
  d. Monitor practitioner practice patterns, appropriateness of care, adherence to practice guidelines, compliance with activities related to HEDIS measures and recommend corrective action. Compare     practice patterns to nationally recognized evidence based guidelines.
  e. Participate in the creation of the annual QAPI Program and Work Plan and the identification of goals, strategies and programs.  Participate in the annual review of the QAPI Program. 

Medical Leadership
Provide medical leadership in the Health Plan:

• As a member of the executive management team, provide medical leadership for the health plan.
• Interact with  providers and IPAs  regarding utilization practices, guideline usage and effective resource management
• Participate in strategic planning with respect to medical aspect of the health plan. 
• Maintain knowledge in general medicine and disease specific national guidelines
• Foster Clinical Practice Guideline implementation and evidence-based medical practice.
• Attend or chair committees such as QAPI, Grievance, peer review, etc. to discuss practice guidelines, quality initiatives and performance improvement projects, case management issues and member grievances and appeals   related to quality of medical care
• Identify utilization review studies and evaluate adverse trends in utilization of medical services, unusual provider practice patterns.
• Identify clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care.
• Interface with other health plan departments, i.e. Member Services, Care Management, Provider Relations, Utilization Management to coordinate operations and programs.
• Support the Provider Relations Department in the education of  the PCP and Specialty networks as it relates to quality of care, adherence to practice guidelines and/or activities designed to improve HEDIS scores
• Participate in regulatory, professional and community activities to provide input and increase knowledge regarding relevant clinical standards and issues.
• Participate in state and local collaboratives and committees as required by DHS and/or as is appropriate for the position at the health plan. 

Minimum Knowledge, Skills and Abilities Required

• Doctorate degree in Medicine
• Masters in Business Administration, Public Health, Healthcare Administration, etc. (Preferred)
• American Board of Medical Specialties Certification (Preferred)
• 2-plus years previous Medical Director experience
• 2-plus years Utilization/Quality Program Management
• 2-plus years experience with Case Management or other nurse or social work clinicians
• 2-plus years HMO/Managed Care operations experience
• 5-plus years Clinical practice
• Willingness to reach out to facilities and physician providers regarding quality and utilization aberrancies
• Prefer Peer Review, medical policy/procedure development, provider contracting experience
• Knowledge of Quality Accreditation Standards. Experience with NCQA and HEDIS measurements

Certification
 
• Board Certification (Primary Care preferred)