24 days old

Chief Medical Officer, CCO

Umpqua Health
Roseburg, OR 97470
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  • Job Code
    153544303
Full Time - Regular
Roseburg, OR, US




POSITION PURPOSE

Under the direction of the Chief Executive Officer, the Medical Director performs utilization management review, participates in the Oregon Health Authority QHOC meetings and subsequent events, and collaborates with executive management on medical-related issues. Performs related administrative and professional work as required.



ESSENTIAL JOB RESPONSIBILITIES
  • Performs utilization review of claims and prior authorizations using regulations and criteria in order to assure optimal efficiency in the management of patient care.
  • Receives and responds to inquiries, concerns and complaints regarding the utilization review process and/or clinical quality of care.
  • Oversees the development and maintenance of Clinical Engagement denial quotes and the Utilization Review Coordinator can do list.
  • Develops and periodically evaluates policies, procedures, and processes that enhance the organization's management of care and resources.
  • Provides insight and training to clinical and administrative staff to help maintain and continuously improve the quality of care.
  • Arranges for the availability of qualified consultative staff, maintains involvement in contract negotiations with these professionals, and represents them to the administration.
  • Participates in Clinical Engagement processes to ensure the appropriateness and quality of medical care and medically related care.
  • Acquires, maintains, and applies knowledge of social, regulatory, political, and economic factors that relate to patient care services.
  • Educates physicians, allied health professionals, managerial staff and the community about managing the continuum of care for optimal utilization of resources.
  • Represents UHA at Administrative Hearings and oversees the Grievance & Appeals process; participates in quality reviews and annual work plans.
  • Works with both the CCO and ATRIO/P3 in developing and reporting metrics.
  • In collaboration with the Pharmacy Director, assists in the development of Medication Guidelines, Formulary management, utilization oversight, network management, and Provider communication.
  • Represents UHA on boards, commissions, committees, associations end/or task forces on a state and local level as appropriate or as appointed; participates in community planning and needs assessment.
  • Reviews, prepares, and/or submits a variety of administrative, fiscal and technical reports.
  • Assists in the development of UHA's
  • Provides clinical insight for technical functions of various case management tools and registries.
  • Participates in the activities of the local health care community and seeks out opportunities for integrating other health programs in the services of UHA Community Information Exchange
  • Collaborates with UHA on integrating and providing oversight of processes and workflows within the CCO.
  • Consults and reviews information regarding requests for credentialing of Providers.
  • Manages high risk cases and third party issues in coordination with the Third Party Recovery team.
  • Schedules daily recurring meetings with utilization management staff.
  • Stays current on prior authorization and utilization management review.
  • Attends a variety of authorized meetings, arriving at or before scheduled times.
  • Performs related work as required.
  • Comply with organization's internal policies and procedures, Code of Conduct, Compliance Plan, along with applicable Federal, State, and local regulations.
  • Other duties as assigned.



GUIDING BEHAVIORS

Accountability

Always demonstrate the highest performance and behavior standards. Share responsibility and expect others to be accountable.

Efficiency

Demonstrate a proactive approach to problem identification and solutions. Be innovative and solutions oriented, improving processes while reducing costs. Demonstrate appropriate time-management skills. Optimize the use of available resources.

Be a Team Player

Support and assist your team members. Be available to help, and learn from your team. Keep an open mind to feedback and earn trust of staff.

Integrity

Keep your promises, commitments, and confidences. Be honest and straightforward dealing with all issues fairly and consistently.

Stewardship

Adhere to all state and federal regulations relating to your position including the Health Insurance Portability and Accountability Act (HIPAA), Fraud & Abuse and Occupational Safety and Health Administration (OSHA) laws. Abide by Company policies and procedures at all times.



CHALLENGES
  • Working with a variety of personalities, maintaining a consistent and fair communication style.
  • Satisfying the needs of a fast paced and challenging company.



QUALIFICATIONS
  • Board-certified medical doctor or doctor of osteopathy in one of the primary care specialties (Internal Medicine, Family Practice or Pediatrics preferred)
  • Licensed physician (MD or DO) in the State of Oregon
  • Leadership experience in a managed care organization or practice setting, including or following strong clinical practice activity.
  • Administrative graduate degree, certificate of educational achievement in medical administration, or equivalent preferred.



PHYSICAL DEMANDS

Typical office environment requiring standing, sitting, walking, bending, and lifting up to 25 pounds. May be exposed to patient and environment conditions such as unpleasant sights, smells and contagious diseases.






PI153544303

Posted: 2021-11-11 Expires: 2021-12-13

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Chief Medical Officer, CCO

Umpqua Health
Roseburg, OR 97470

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