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Managed Care Medical Director

Employer
AIDS Healthcare Foundation
Location
Los Angeles, California
Posted Date
Dec 1, 2015

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Under the supervision of the Chief of Managed Care, the Managed Care Medical Director is responsible for the appropriateness and quality of medical care delivered to members through the AHF Medicare and MediCal health plans and certain Ryan White contract(s). The Medical Director is responsible for projecting and integrating the Mission and Core Values of the AIDS Healthcare Foundation (AHF) as well as AHF’s Management Philosophy of a management elements: mission driven, fairness, learning, hands-on, accountability ,and tenacity in the leadership of the health plans quality, utilization and care delivery systems and processes.

As a member of the Executive Management Team you will collaborate with medical staff across the organization including (Managed Care Directors, Healthcare Center Medical Directors, Quality Improvement, Utilization Management)  in managing and executing the Medicare and MediCal Models of Care, fiscal and operational objectives, regulatory/contractual/ compliance/accreditation requirements, and achieving the quality outcome goals of the Medicare/MediCal Chronic Care Special Needs Health Plans, MediCal AIDS Waiver, Ryan White Medical Care Coordination and Medical Subspecialty Referral Program, and other programs as assigned.

Essential Duties and Responsibilities for the Medical Director for Managed Care:

  1. Clinical oversight to the Utilization Management (UM) Program and UM Work Plan. Along with Plan executive teams you will develop, implement, and update a comprehensive UM program to ensure it meets AHF and other contractual, regulatory, and accrediting agency requirements.                                     
  2. Clinical input into the development of the Quality Improvement Plan and improvement activites related to HEDIS, CDC, HRSA, HOS, and CAHPS quality indicators and collaborates with the National Director of Quality Management to assure continuing improvement and achievement of a high quality delivery system, e.g., 5 STAR Medicare Plan, 3-year Model of Care certification, 3-year AAAHC accreditation, Ryan White surveys, audits without findings, or significant corrective action plans.
  3. Participates in developing departmental and division goals that reflect the vision of the organization.
  4. Participates in the development of the annual budget for the Managed Care Division.
  5. Works with Business Analyst to develop reports and analyze claims, utilization patterns and trends. Develops action plans in concert with Director of UM/CC and medical network to implement change.
  6. Reviews clinical and fiscal performance of health plans with staff on a monthly basis. Collaborates with the Director of Contracts and Finance Management.

Education and/or Experience:

  • Medical Degree either MD or DO
  • Masters in Public Health (MPH) and/or Masters in Business Administration (MBA) and/or Masters in Health Administration (MHA) a plus
  • Board Certified in PrimaryArea of Medicine, Family Practice, Internal Medicine, or Subspecialty of Infectious Diseases
  • Minimum of five years clinical medical experience post residency training
  • Minimum of three years experience in HIV/AIDS treatment preferred
  • Knowledge and understanding of state specific Medicaid and Medicare programs
  • Maintain clinical knowledge in HIV/AIDS medicine and intimate knowledge of the Department of Health and Human Services HIV/AIDS guidelines

Certificates, Licenses, and Registration

  • State of California Board License (without restrictions)
  • Obtain FL medical license within nine months of employment
  • Maintain or obtain after 24 months of employment a AAHIVM non-practicing HIV Expert AAHIVM certificate

If you would like to be considered for this opportunity, please submit your resume to: Miyoshi.LaFourche@aidshealth.org.

EOE/AA

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