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Department

Job Summary

The Medical Director of Managed Care functions as the Denver Health Medical Plan's Chief Medical Officer and is responsible for the development, implementation and evaluation of medical management activities carried out by Managed Care on behalf of its members. The overarching goals of these activities are to fulfill regulatory requirements, improve member care and outcomes, reduce unnecessary health care expenses, and insure that clinical services are provided in a manner consistent with each health plan's benefits.


Essential Functions:

• Supports relevant functions of the Pharmacy and Quality Improvement & Accreditation Departments and utilization, care, and disease management processes. (5%)
• Serves as a liaison to the clinical departments at Denver Health. Responsible for educating Denver Health?s clinical providers about the Medical Plan?s benefit plans and management resources, including how to refer members in need of those resources, request prior authorization approval, and how to collaborate with Managed Care to meet our shared goals and objectives. (5%)
• Supports Managed Care?s medical management initiatives with the clinical activities in Denver Health?s inpatient and outpatient settings. (5%)
• The Medical Director may serve on various Denver Health Committees. (5%)
• Provides clinical oversight and support for the Medical Management areas of: Pharmacy, Quality Management and UM/CM/DM. (5%)
• Engages with Denver Health and external providers to address practice patterns to ensure member care and quality initiatives. (5%)
• For each line of business in the Medical Plan, develops and monitors annual cost and utilization targets for key medical service areas such as: pharmacy, admissions, LOS, re-admissions, ED utilization. Implements initiatives to improve areas that do not meet established targets. (5%)
• Evaluates utilization, national and local trends and identifies interventions to optimize the utilization of resources, control cost and delivery of quality health care services. (5%)
• Monitors medical costs outside of Denver Health. Identify areas of opportunities to bring more services into Denver Health. (5%)
• Provides clinical direction to the Quality Management, Pharmacy and Medical Management Departments in the development of clinical initiatives and programs for the annual Quality Improvement Work Plan by line of business. (5%)
• Responsible for supporting the Quality Improvement Program for Denver Health Medical Plan and Denver Health Medicaid Choice. (5%)
• Responsible for analyzing HEDIS results for all lines of business and reviewing Quality Improvement measures and others areas to identify clinical measures for planned interventions. (5%)
• Oversees the process of reviewing quality of care concerns and remediating identified quality of care problems. (5%)
• Remains abreast of applicable contractual and regulatory quality clinical requirements for Medicaid/CHP, Medicare, Commercial and Exchange lines of business. (5%)
• Works with the Quality Management, Pharmacy and Medical Management Departments on the implementation of processes, policies and programs to meet all requirements. (5%)
• Ensures that all contractual, regulatory and accreditation requirements are met by Medical Management functional areas. Participate in on-site audits. (5%)
• Represents the Plan in external regulatory audits, HEDIS audits, and accreditation site reviews for medical management. (5%)
• Meets as needed with applicable regulatory agencies and contractors to clarify requirements, resolve issues, develop, and collaborate on programs to meet such requirements. (5%)
• Promotes the development of innovative programs that meet members? healthcare needs, promote disease management, and improve behavioral health and wellness. (5%)
• Develops and implements plans to improve employee engagement in collaboration with department directors and their managers. (5%)

Education:

• Doctorate Degree required

Work Experience:

• 10+ years Clinical practice experience required and
• Three years of managed care experience (either in a medical group or health plan) in utilization management, population health, disease management, health care quality improvement programs, or clinical guideline development and implementation required or
• Three years managerial experience required

Licenses:

• MD-Physician - State Medical Board required

Knowledge, Skills and Abilities:

• Demonstrates an understanding of quality improvement, population health, disease management, utilization, case and disease management programs and healthcare financing and costs.
• Ability to develop collaborative relationships with internal departments and providers at Denver Health as well as all external providers and partners.
• Must have effective oral and written communications skills.
• Knowledge of NCQA and managed care regulations/requirements for HMO, Medicaid and Medicare Advantage preferred.
• Experience working in an outsourced UM/CM/DM environment preferred.
• Computer skills required.

Shift

Work Type

Salary

Benefits

• Outstanding benefits including up to 27 paid days off per year, immediate retirement plan employer contribution up to 9.5%, and generous medical plans

• Free RTD EcoPass (public transportation)

• On-site employee fitness center and wellness classes

• Childcare discount programs & exclusive perks on large brands, travel, and more

• Tuition reimbursement & assistance

• Education & development opportunities including career pathways and coaching

• Professional clinical advancement program & shared governance

• Public Service Loan Forgiveness (PSLF) eligible employer+ free student loan coaching and assistance navigating the PSLF program 

• National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer

Our Values

• Respect

• Belonging

• Accountability

• Transparency

All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made.

Denver Health is an integrated, high-quality academic health care system considered a model for the nation that includes a Level I Trauma Center, a 555-bed acute care medical center, Denver?s 911 emergency medical response system, 10 family health centers, 19 school-based health centers, Rocky Mountain Poison & Drug Safety, a Public Health Institute, an HMO and The Denver Health Foundation.

As Colorado?s primary, and essential, safety-net institution, Denver Health is a mission-driven organization that has provided billions in uncompensated care for the uninsured. Denver Health is viewed as an Anchor Institution for the community, focusing on hiring and purchasing locally as applicable, serving as a pillar for community needs, and caring for more than 185,000 individuals and 67,000 children a year.

Located near downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.

Denver Health is an equal opportunity employer (EOE). We value the unique ideas, talents and contributions reflective of the needs of our community.

Applicants will be considered until the position is filled.

About Denver Health

Take your career to the next level at Denver Health, where we offer a robust benefits package and endless opportunities for growth. Denver Health is a nationally-ranked, locally-trusted, premier healthcare institution located in the heart of Denver, Colorado.Twenty-five percent of all Denver residents, or approximately 150,000 individuals, receive their health care here. We are known as an integrated health care system that encompasses multidisciplinary academic specialties, a community health system, a level I adult trauma center, pediatric emergency and urgent care center home to Denver Public Health and many of the nation's leaders in medicine.Denver Health is an Equal Opportunity Employer At Denver Health we pride ourselves on our commitment to diversity. Equal opportunity is a fundamental principle of Denver Health. As an equal opportunity employer, Denver Health is committed to recruit, hire, promote and administer all human resource actions in a non-discriminatory manner. Denver Health is committed to providing equal opportunities in all business practices and to all persons regardless of age, race, color, national origin, genetic information, religion, sex, pregnancy, disab...ility, sexual orientation, gender identity, gender expression, marital status or veteran status (collectively “protected status”). Denver Health strives to maintain a work environment that is free from unlawful harassment and discrimination and will not tolerate any such conduct by employees or directed at employees within the scope of their employment. Read the full Human Resources Employee Principles and Practices policy.

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