Summary Description:
The Assistant Medical Director focuses on helping ensure high-quality, efficient care for our members through thoughtful clinical review, vendor and delegation support, and strategic contributions to population health and quality programs. This role does not manage teams directly, but influences outcomes across multiple departments and touchpoints
Representative Duties:
Utilization Management
Review complex medical cases (e.g., second opinions, investigational/experimental requests, transgender, transplant, and out-of-area cases)
Apply evidence-based criteria (e.g., InterQual, CMS, MCG) in alignment with internal policies and regulatory standards
Collaborate with WHA’s Director of Utilization Management and the UM Committee
Assist in preparation of Board-level clinical reporting
Complete peer to peer review requests
Participate in case discussions and plan decision defense with DMHC
Interface with clinical providers at medical groups or at out-of-area facilities to improve transition of care
Optimize denial letters to standardize language and improve member and provider education
Strictly observe DMHC turn-around times, NCQA standards and CMS rules
Provide input on benefit design and new medical technology review. Delegated Oversight & Support
Participate in clinical audits and performance reviews of delegated medical groups
Help review and resolve escalated UM or quality issues in collaboration with provider partners
Support medical group engagement meetings and workgroups with clinical input
Support CMO in assuring delegated entities are compliant with regulatory oversight
Participate in DMHC audit activities and NCQA survey activities
Quality & Population Health
Collaborate with Quality and Population Health teams on clinical initiatives that improve HEDIS scores, care gap closure, and member outcomes
Assist with regulatory readiness (e.g., NCQA, DMHC), quality committee input, and data interpretation
Support integration of health equity and disparities into clinical reviews and performance strategies
Support efforts to achieve 4.5 NCQA stars
Help support Pay for Performance development, set incentive targets for quality metrics, share medical group reports
Vendor Collaboration
Assist in clinical coordination with vendors supporting utilization review, behavioral health, or population health programs
Provide clinical insight on vendor performance and alignment with plan policies
Support clinical vendor management and assessment of prospective vendors
Clinical Guidance & Innovation
Help inform benefit coverage interpretations, medical necessity criteria, and policy review
Contribute to small pilots or innovation efforts (e.g., diabetes, GLP-1 management, behavioral health access.)
Serve as a clinical resource for internal departments (e.g., member services, grievances. Committee Involvement
Participate in QIC Committee, Pharmacy Oversight Committee, PQI Committee, Appeals Review meetings, UM/CM Quarterly Workgroups, WHA educational/sales forums
Sales and Marketing
Provide consultative support to the Sales department
Provide OOA case review and participation in OOA work groups
Interface with brokers, medical groups. WHA peers and members as needed
Additional Duties:
Will have moderate travel, including to conferences, broker meetings, and Hospital and Medical group site meetings
Additional projects assigned by the Chief Medical Officer
Qualifications:
MD. or DO. with a valid license to practice medicine without restriction, in the state of California
Diplomate with American Board of Medical Specialties or American Board of Osteopathic Medicine with current/updated certification
5 years’ clinical experience in primary care or hospitalist medicine
3 years’ experience working with capitated HMO patients
2 years’ experience in medical administration
Proficient computer skills, including electronic mail, routine database activity, word processing, spreadsheet, graphics, etc
Must be able to speak, read, write, and understand the primary language(s) used in the workplace
Salary:
$250,000.00-$275,000.00 Annually
Western Health Advantage is committed to providing equal employment opportunities to employees and applicants for employment on the basis of merit and without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, physical or mental disability, medical condition, genetic information, marital status, ancestry, military or veteran status, or any other basis made unlawful by federal or state law.
Western Health Advantage values and supports the unique talents and strengths that each employee brings to our organization. Collaborating with the best and the brightest means a dynamic, fulfilling work experience for you — and excellent customer service for our members.
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