Primary Purpose

Oversees medical coordination required for effective utilization and quality management of the health plan network. Supports the clinical activities of PCHP Utilization Management, Quality Management, Clinical Policy, Technology Assessment, Credentialing, Population Health and Fraud, Waste and Abuse Functions to assure comprehensive, high quality health care to plan members in accordance with managed care and PCHP policies. Monitors clinical care needed to produce optimal health outcomes and cost-effective care.

Minimum Specifications

Education

- Must have successfully completed an Accreditation Council for Graduate Medical Education (ACGME) or American Medical Association (AMA) approved residency in an appropriate specialty to the PCHP population.

- Master's degree in business administration, healthcare administration, or a related discipline preferred.

Experience

- At least five (5) years of clinical practice experience in a specialty relevant to the care of PCHP members.

- Experience in the development of medical policies, procedures and programs is preferred.

- Qualifications to perform clinical oversight for the services provided by the health plan to include but not limited to education, training or professional experience in medical or clinical practice preferred.

- Past participation in a managed care UM committee preferred.

- Peer Review, medical policy/procedure development experience preferred.

- Experience in Utilization/Quality Program management preferred.

Certification/Registration/Licensure

- Must be currently licensed for the practice of medicine in the State of Texas.

- Must meet and maintain licensing and registration requirements as required by the State of Texas for Managed Care Medical Directors.

- Board certification in the relevant specialty preferred

Skills or Special Abilities

- Excellent verbal and written communication skills including the ability to communicate effectively and professionally across disciplines and with a variety of constituents as well as the ability to articulate complex information in understandable terms.

- Working knowledge of managed care principles and Texas Medicaid Regulations is preferred.

- Must understand and demonstrate knowledge of principles of care coordination and collaboration, population health and social determinants of health, clinical evaluation of evidence-based care and value based purchasing.

- Must be familiar with the role of pharmacy and behavioral health in managing health care.

- Ability to apply medical knowledge and principles to business challenges in order to achieve significant member, business, and quality outcomes.

- Demonstrated ability to coach and influence for results.

- Strong interpersonal and conflict resolution skills with the ability to establish and maintain effective working relationships with diverse groups across and beyond the organization.

- Strategic thinking and long-range planning skills with the ability to lead major organizational initiatives, accomplish results, and achieve measurable outcomes or goals.

- Ability to work in challenging situations involving competing interests, and high level-interdisciplinary groups.

- Excellent time management and organizational skills with the ability to manage multiple demands and respond to rapidly changing priorities.

- Strong analytical and problem-solving skills.

- Knowledge of Texas Medicaid (STAR, STAR Kids/CHIP) program, National Committee for Quality Assurance (NCQA), the Uniformed Managed Care Contract, and the Uniform Managed Care Manual.

- Sound business acumen.

- Proficient Microsoft Office and computer skills.

Responsibilities

Operations

• Reviews prior authorization, concurrent, and pre-service and post-service appeals request for medical necessity and resolves grievances related to medical quality of care.
• Participates in identification and analysis of process improvement of jobs design, work processes, and workflows for the clinical area and implements appropriate changes to improve effectiveness, productivity, and efficiency that support the overall goals of the managed care delivery system and PCHP.
• Facilitates conformance to Medicaid, NCQA and other regulatory requirements.
• Provides clinical oversight for utilization management, disease management and quality management activities as assigned by the PCHP Chief Medical Officer or Medical Director including participation in development of medical policies and procedures for coverage and authorization and clinical standards and guidelines based on evidence-based medicine. As assigned by the Chief Medical Officer or Medical Director, serves as chairperson or member of managed care committees, and participates on various community and interdisciplinary committees.
• Performs peer to peer calls as necessary to support the utilization management process.

Strategy

• Assists the Chief Medical Officer or Medical Director in oversight, evaluation, and administration of the clinical aspects of PCHP fraud, waste and abuse programs.
• Assists the Chief Medical Officer or the Medical Director and the Pharmacy Director of PCHP in overseeing and administering the pharmacy benefit for PCHP members including coordination of care between the Medical and Pharmacy benefits.
• Analyzes data to establish health care provider profiles and define acceptability of physician performance and evaluates the effectiveness of UM practices by actively monitoring for over and under-utilization.
• Participates in development, implementation, and monitoring of annual goals and objectives for PCHP that support the mission and objectives of Parkland.
• Participates in assessment of existing education programs offered to providers and members, developing and evaluating such programs, and provides implementation support for Quality Improvement activities.

Quality

• Integrate health literacy principles into all communication including Members and Providers.
• Support strategies that meet clinical, quality and network improvement goals.
• Promote the use of Health Information Technology to support and monitor the effectiveness of health and social interventions and make data-driven recommendations as needed.
• For staff in clinical roles, foster collaborative relationships with members and/or providers to promote and support evidence-based practices and care coordination.

Regulatory

• Develop processes to maintain compliance with regulatory agencies and accrediting bodies. Ensures operations are carried out in compliance with these regulations.

As assigned by the Chief Medical Officer or Senior Medical Director, assists in representing PCHP on clinical activities with relevant State and local bodies such as the Texas Department of Insurance, Texas Health and Human Services Commission, and Texas Medical Association

• Works collaboratively with others to validate and sustain compliance with regulatory and accreditation standards.
• Conducts routine compliance audits identifying gaps and implementing remediation plans as necessary.
• Works collaboratively with leadership and/or PCHP Compliance to investigate and respond to matters of concern or alleged violations taking corrective action as necessary.
• Provides timely and accurate responses to requests for information from regulatory agencies and accrediting bodies.

Fiscal Management and Operating Budget

• Promote activities to achieve operational efficiency.
• Consider operational outcomes and financial implications when making recommendations to implement new programs or modify current programs.

Professional Accountability

• Acts with the highest integrity and ethical standards while adhering to Parkland's Mission, Vision, and Values. Adheres to organizational policies, procedures, and guidelines.
• Completes assigned training, self-appraisal, and annual health requirements timely.
• Adheres to hybrid work schedule requirements. Attends required meetings and town halls.
• Recognizes and communicate ethical and legal concerns through the established channels of communication.
• Demonstrates accountability and responsibility by independently completing work, including projects and assignments on time, and providing timely responses to requests for information.
• Maintains confidentiality at all times.
• Performs other work as requested that is reasonably related to the employee's position, qualifications, and competencies.

Job Accountabilities

1. dentifies and analyzes the design of jobs, work processes, work flows, etc. for the area and implements appropriate changes to improve effectiveness, productivity, and efficiency that support the overall goals of the department and Parkland.
2. Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices.
3. Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and federal, state, and private health plans. Seeks advice and guidance as needed to ensure proper understanding.
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