Pacific Medical Centers Medical Director, US Family Health Plan (USFHP) in Seattle, Washington
Reporting to the Chief Medical Officer, Value Based Care & Ambulatory Quality, Puget Sound, the Medical Director of USFHP is responsible for the USFHP’s compliance, quality, utilization management, credentialing, and network programs. In this capacity, the individual is to ensure, with the Director of USFHP and PacMed’s CEO, the cost effectiveness, appropriateness, and quality of health services provided to USFHP. This position works in a collaborative partnership relationship with the Director of USFHP.
Essential Duties :
Provides overall vision and consistent leadership across USFHP in all areas related to quality improvement (QI),
Utilization management (UM) and compliance.
Provides guidance for clinical operational aspects of USFHP
Provides oversight of clinical decision-making functions of the Plan
Ensures compliance with USFHP policies and network expectations regarding UM, QI, and compliance.
Promotes the principles and the active use of skills and tools embodied in total quality improvement management theory.
Participates in the hiring process for USFHP clinical staff
Develops clear objectives and goals to optimize the organization’s delivery of quality, cost effective health care.
Responsible for timely implementation and monitoring of programs that achieve the stated goals and objectives.
Participates in the analysis of outside purchased service reports and the development and implementation of related expense reduction policies and programs.
Works collaboratively in a team oriented fashion with the Executive Director of USFHP to provide physician leadership, direction, and support (when appropriate) to all aspects of this individual’s work.
Responsible for first-level utilization management appeals in the areas of: benefit interpretation, claims review, the provision of high-cost services, and investigation of new technology as identified by Medical Leadership, or the Executive Director of USFHP.
Ensures optimal utilization of acute and extended care facilities.
Communicates and reinforces managed care standards with providers.
Participates in the development of standard quality and utilization reports for individual providers and groups across the organization.
Develops, implements, and maintains USFHP’s Clinical Quality Management Program and its associated programs.
Provides leadership and support in the provision of consistent and high-quality care.
Provides medical leadership in USFHP’s service, access and quality programs.
Ensures that quality improvement initiatives are widely embraced and utilized by the medical providers through consistent communication and monitoring and that these initiatives are regularly reevaluated and updated as appropriate.
Coordinates quality improvement efforts with our strategic partners, the health plans, and regulatory agencies.
Oversees the successful development, implementation, and monitoring of the USFHP’s complaints management and quality program.
Coordinates medical quality review with the network Medical Leadership when a patient or member of our clinical staff or administration identifies a questionable outcome.
Develops, implements, and reports key measures of quality outcomes with specific attention to HEDIS criteria.
Provides guidance for all clinical aspects of the Network Program
Responsible for the clinical aspects of the Network Program
Provides ongoing consultations with practitioners in the field
Designated physician responsible for implementing and overseeing the Credentialing Program
Provides periodic consultations with practitioners in the field
Allocation of resources required to achieve credentialing goals
Responsible for oversight of the clinical aspects of the credentialing program
Provides medical leadership to ensure that providers are meeting reasonable standards of care and are accountable to the Plan for their decisions affecting members
Ad hoc member of the Quality and Care Coordination Committee of PacMed
USFHP Quality, Safety and Utilization Management Committee
Medical doctorate or allied medical degree.
Five years direct patient care experience with exemplary performance including at least three years within a managed care setting preferred.
Training and/or experience in medical management and medical leadership with special emphasis on quality and utilization management.
Board certification required.
Current unrestricted clinical license.
We offer comprehensive, best-in-class benefits to our caregivers. For more information, visit https://pacmed.jobs/benefits/
Our mission is to provide respectful, high-quality, patient-focused healthcare to each person and to the communities we serve.
Quality and respect. These are the words Pacific Medical Centers (PacMed) employees live and work by. PacMed is a private, not-for-profit, primary and integrated multispecialty health care network with 10 outpatient clinics across the Puget Sound region and more than 175 primary and specialty care providers. Affiliated with the Providence Health & Services system, PacMed provides patient-focused health care — and even same-day appointments — to patients in King, Snohomish and Pierce counties. We provide immediate access to cutting-edge technology, first-class facilities and board-certified specialists, many of whom have been listed as among “Seattle’s Best Doctors.”
Pacific Medical Centers, PacMed, and their Affiliates' (collectively “PacMed”) comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. PacMed does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
Job Category: Physician
Req ID: 311256