Medical Director - Benefit/Utilization Management

• Medical policy knowledge and skills as related to quality, case and disease management, credentialing activities and utilization management • Excellent communication and collaboration skills for work with network providers and internal employees • Ability to effectively express ideas and gain their acceptance • Ability to implement new and improved approaches to improvement of care and service quality, and to Care Management activities performed by CareOregon • Ability to implement clinical and wellness programs to address the needs of high-risk members • Ability to work effectively as part of a cross-functional team and foster an environment where change is embraced and supported • Ability to deal with issues and problems systemically • Ability to work as an integral part of a team • Ability to plan, set priorities, delegate effectively and utilize time efficiently • Ability to apply innovative and creative approaches to improve health care delivery • Skills in quality management techniques to apply in a large, organized managed care setting • Commitment to improving access and quality of care to the underserved and uninsured • Appreciation of cultural diversity and the needs of serving a diverse patient population • High degree of diplomacy, credibility and persuasiveness to consistently cultivate effective working relationships • An organized, disciplined, hands-on and process-oriented leader • Persistent, assertive, data driven and focused • Proactive and action oriented; drives performance • High degree of initiative and motivation along with the ability to effectively support and collaborate with others to achieve business objectives • Ability to work effectively with diverse individuals and groups • Ability to learn, focus, understand, and evaluate information and determine appropriate actions • Ability to accept direction and feedback, as well as tolerate and manage stress • Ability to see, read, and perform repetitive finger and wrist movement for at least 6 hours/day • Ability to hear and speak clearly for at least 3-6 hours/day

Medical Director - Benefit/Utilization ManagementThis position is responsible for oversight of clinical and wellness programs and initiatives in support of CareOregon members. Areas of focus may include benefit management, benefit utilization, quality assurance, case management, disease management, pharmacy, or other areas. Note: This is a 0.8 position with benefits. The hiring range listed would be pro-rated to reflect 0.8. Estimated Hiring Range: $294,570.00 - $360,030.00 Bonus Target: Bonus - SIP Target, 10% Annual Priority will be given to candidates residing in Oregon and Southwest Washington. Current CareOregon Employees: Please use the internal Workday site to submit an application for this job. Essential Responsibilities • With the Senior Medical Director, develop, implement and manage clinical and wellness programs to address the needs members. • Implement, direct and oversee utilization, case, disease, and/or quality management programs. • Develop and implement programs for educating participating physicians regarding quality management and utilization management issues. • Represent the health plan in applicable activities including medical and other professional organizations. • Participate in activities that enhance CareOregon’s image within the community. • Serve as a representative and medical spokesperson for the plan in support of Coordinated Care Organizations (CCOs), contract negotiations and other provider expansion activities. • Provide leadership necessary to maintain a motivated, productive and competent team through open communication and delegation of responsibilities and authority. • Provide medical support for Care Management/Care Coordination activities. • Provide medical director oversight, benefit determinations and appeals for medical and pharmacy as assigned by Senior Medical Director. • May integrate with CCO/Line of Business (LOB) Medical Directors to develop, implement, direct, and oversee programs that provide clinical strategy and interventions to CCO/LOB clinical systems. • Support and implement programs for educating network providers regarding best clinical practice using of population/panel management and performance data on clinical quality and utilization. Experience and/or Education Required • Board-certified medical doctor or doctor of osteopathy in one of the primary care specialties, including obstetrics/gynecology (Internal Medicine, Family Practice, Emergency Medicine, or Pediatrics preferred) • Licensed physician (MD or DO) in the State of Oregon • Minimum 3 years’ physician experience Preferred • Minimum 4 years’ experience in a supervisory position • Benefit/utilization management experience • Leadership experience, preferably to include managed care, quality assurance, utilization review and case management experience Knowledge, Skills and Abilities Required Knowledge • Clinical knowledge of the management of diverse medical problems • Basic knowledge of applicable regulatory and contractual requirements for Medicaid, Medicare and commercial insurance • Understanding of managed care operations • Familiarity with guideline development, outcomes management, population health improvement, disease management and cost effectiveness and cost analysis studies • Awareness of physician/provider payment issues, physician practice models and total quality and continuous quality improvement concepts Skills and Abilities • Medical policy knowledge and skills as related to quality, case and disease management, credentialing activities and utilization management • Excellent communication and collaboration skills for work with network providers and internal employees • Ability to effectively express ideas and gain their acceptance • Ability to implement new and improved approaches to improvement of care and service quality, and to Care Management activities performed by CareOregon • Ability to implement clinical and wellness programs to address the needs of high-risk members • Ability to work effectively as part of a cross-functional team and foster an environment where change is embraced and supported • Ability to deal with issues and problems systemically • Ability to work as an integral part of a team • Ability to plan, set priorities, delegate effectively and utilize time efficiently • Ability to apply innovative and creative approaches to improve health care delivery • Skills in quality management techniques to apply in a large, organized managed care setting • Commitment to improving access and quality of care to the underserved and uninsured • Appreciation of cultural diversity and the needs of serving a diverse patient population • High degree of diplomacy, credibility and persuasiveness to consistently cultivate effective working relationships • An organized, disciplined, hands-on and process-oriented leader • Persistent, assertive, data driven and focused • Proactive and action oriented; drives performance • High degree of initiative and motivation along with the ability to effectively support and collaborate with others to achieve business objectives • Ability to work effectively with diverse individuals and groups • Ability to learn, focus, understand, and evaluate information and determine appropriate actions • Ability to accept direction and feedback, as well as tolerate and manage stress • Ability to see, read, and perform repetitive finger and wrist movement for at least 6 hours/day • Ability to hear and speak clearly for at least 3-6 hours/day Working Conditions Work Environment(s): ☒ Indoor/Office ☐ Community ☐ Facilities/Security ☐ Outdoor Exposure Member/Patient Facing: ☒ No ☐ Telephonic ☐ In Person Hazards: May include, but not limited to, physical and ergonomic hazards. Equipment: General office equipment Travel: May include occasional required or optional travel outside of the workplace; the employee’s personal vehicle, local transit or other means of transportation may