Practice Opportunities - Information
Specialty: Medical Director, Health Plans & Network Mgmt
Location: Sacramento, CA
(Sutter Medical Group)
Medical Director, Health Plans and Network Management
The primary responsibility of the Medical Director, Health Plans and Network Management is management and oversight of all aspects of SMG's programs with health plans that require active management of cost and utilization, including both HMO and PPO plans. In addition, this position is charged with improving internal capture of all medically appropriate referrals for SMG.
FTE: 1.0: Clinical work of up to 0.2 FTE is encouraged, but not required.
1. Develop guidelines for appropriate utilization and partner with SMG clinicians to implement
2. Identify areas where out of group referrals can be appropriately minimized. Develop plans to partner with Physicians to reduce out of group referrals
3. Work with SMG clinicians to develop and implement referral agreements for various clinical conditions
4. Identify internal SMG causes for out of group referrals and work with the primary care and specialty care medical directors to remediate those causes.
5. Oversee PPO shared savings programs for SMG and partner with other stake-holders to improve results
6. Conduct regular case review and consultation with case managers, both in ambulatory and acute settings. Work with hospital utilization directors on case escalations where appropriate.
7. Develop review processes for service authorizations/denials that meet compliance standards with the health plans and Sutter Connect
8. Evaluate requests for medical services that require Medical Director approval, including out-of-network services and provider appeals, or supervise this function
9. Develop strategies to address identified areas of improvement in appropriate utilization of services to maximize group savings
10. Discuss cases with Health Plan Medical Directors as required to come to resolution
11. Help develop a managed care dashboard for both specialty and primary care physicians
12. Identify specialty departments where drill down reports can identify variation reduction projects
13. In conjunction with SPA Administration, implement and assist in the management of the market share caps
14. Develop ability to participate in network contracting
15. Work in conjunction with SPA Administration in developing SPA budget
16. Work with all stake-holders to improve transitions of care
A. Board Certified, M.D. or D.O, with a valid California License to practice medicine, with 5 years experience in clinical practice
B. Prior experience with utilization review and/or medical management experience is preferred
C. Positive interpersonal skills such to foster positive communications and working relationships with physicians, executive and administrative staff
Sacramento, the state capital of California, is the core cultural and economic engine of a four-county metropolitan area exceeding 2.1 million residents. Sacramento is the seventh most populous city in California. Greater Sacramento has been cited as one of the five most livable regions in America.
The city offers a wealth of cultural diversity and ample activities, including museums, parks and historical sites. Sacramento has close access to fabulous lakes and rivers, snow sports and beautiful trails for running, hiking, biking, etc. Whether it is honoring its Gold Rush beginnings in Old Sacramento or cheering on its professional basketball team, the Sacramento Kings, or its minor league baseball club, the Sacramento River Cats, the city celebrates its past and present.
Centrally located, it is an hour and a half from the mountains of Lake Tahoe or the bay of San Francisco. For the wine connoisseur, scenic Napa Valley is just a short drive away.
Links to more community information
- Metro Chamber of Commerce Opens new window
- Sacramento Valley Online Opens new window
- California State University, Sacramento Opens new window
- Sacramento City Search Opens new window
- Sacramento Bee Opens new window
- Sacramento Magazine Opens new window
For more information contact
Those interested in applying should send their CV and statement of interest to Kristin Hallmark