Work in Washington Veterans Jobs

Senior Medical Director Washington - includes in state and out of state travel Single large employer focus Primary Job Purpose Senior Medical Director provides clinical leadership and support to clinical teams to ensure HCA members receive quality, cost effective care yielding optimal outcomes, supports HCA's Health Technology Assessment program, the Prescription Drug Program, the Bree Collaborative, HEDIS and CAHPs performance and quality program, and other the HCA-identified performance improvement efforts as they relate to the UMP Plans and the State's health care purchasing system. This will include HCA customized medical policies and medical benefit design, WA state legislative mandates, clinical escalation support, participation in development of and organizational alignment to Bree Collaborative best practice recommendations, participation in development of care transformation strategic initiatives, and other requests from HCA. General Functions and Outcomes * Provides clinical leadership for staff to ensure members receive safe, effective and cost efficient services. * Contributes to the development of various medical management strategies and tactics to drive results and achieve key performance metrics. * Conducts peer clinical review for medical necessity on utilization management authorization requests. * Provides clinical input on case management reviews working closely with the CM clinical staff. * Responsible for discussing review determinations with providers who request peer-to-peer conversations. * Participates on multiple teams to provide clinical input on medical policy reviews and development and may participate on committees that develop programs impacting clinical interventions, utilization management and case management. * Analyzes and uses data to guide the development and implementation of health care interventions that improve value to the member and employer. * Advises Health Care Services Leaders on related key performance metrics and the effectiveness of various efforts, initiatives, policies and procedures. * Identifies and communicates new opportunities in utilization management, provider contracting or other areas that would enhance outcomes and the reputation of the organization. * Provides clinical expertise and coordinates between internal clinical programs and providers of care to improve the quality and cost of care delivered to health plan members. * Ensures ethical decision making in compliance with contractual arrangements, regulations and legislation. * Supports internal communication or training that ensures service is provided to members and providers by a well-trained staff. * Promotes provider understanding of utilization management and quality improvement policies, procedures and standards. * Provides guidance and oversight for clinical operational and clinical decision-making aspects of the program. * Has periodic consultation with practitioners in the field and ensures that the organization has qualified clinicians accountable for decisions affecting consumers. * May manage staff including hiring, performance management, development and retention. * May participate in health plan credentialing operations and clinical aspects of the credentialing program and provider services support. Minimum Requirements * Demonstrated competency working with hospitals, provider groups or integrated delivery systems to effectively manage patient care to improve outcomes. * Strong communication and facilitation skills with internal staff and external stakeholders, including the ability to resolve issues and seek optimal outcomes. * Proven ability to develop and maintain positive working relationships with community and provider partners.