Looking for a way to make an impact and help people?

Join PacificSource and help our members access quality, affordable care!

PacificSource is an equal opportunity employer.  All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.

Diversity and Inclusion:  PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths.

Actively engage with the provider community across all lines of business (LOB) in support of the strategic and operational goals of PacificSource. Provide clinical expertise for physical, behavioral, and oral health utilization management, as well as health promotion, disease management, pharmacy review, dental case review, grievance and appeals, quality programs, and cost of care management. Manage and coordinate externally facing operations of appropriate departments and interface with appropriate regulatory agencies to influence, understand, and implement policies and procedures. Work in collaboration with regionally based PacificSource staff as well as regional physicians and health care leaders to meet or exceed quality standards and to coordinate and facilitate work across lines of business and organizations to optimize operational and community effectiveness. <br>

Essential Responsibilities:

Lead the cross-organizational clinical work using process improvement techniques to analyze, identify, and implement changes to workflow, staff, and organizational structure that improve operational efficiency and effectiveness.Attend and participate in all relevant local and PacificSource Care Management, Cost Management, Clinical, Quality, Utilization Management Committees, clinical advisory forums, and activities. Prepare and participate in agendas, collaborate with the committees, research topics, and follow through on decisions and tasks.Actively participate as a key team member in relevant Manager/Supervisor meetings including meetings related to Population health, Provider Network, Quality, Risk, and Health Services Teams, as convened by Chief Medical Officer (CMO) or designee.As appropriate, function as liaison between the local provider community and PacificSource clinical enterprises to facilitate coordination and the execution of work.As appropriate, review and manage appeals, and lend expertise to the preparation of cases for further external review, including OHA hearings.As appropriate, provide expertise and medical interpretation with respect to claims adjudication, contract language, disputes and appeals, policy drafts, and care management issues.As appropriate, oversee the management of appropriate care and case management related to acute, catastrophic, and long-term cases.As appropriate, participate as a subject matter expert in Cost of Care working groups, to include anticipation of trends impacting global budget, and proactively addressing those trends in line with Quadruple Aim goals.As appropriate, review pre-authorizations, claims, and other cases involving pre- or post-service requests for coverage.As appropriate, conduct other utilization review activities (e.g., lengths of stay, appropriateness of service, intensity of service, medical necessity, and experimental/investigational services) on a prospective, concurrent, or retrospective basis.As assigned, assist with credentialing review of providers and the resolution of issues brought forward by credentialing staff. Help to staff the Credentialing Committee, prepare agendas, present practitioner issues, develop policies, and oversee actions of the committee.As assigned, assist with Pharmacy and Therapeutics Committee functions, as defined by Pharmacy Director.Assist the Chief Medical Officer or his designee, as requested, including periodic involvement with providers, and members, PacificSource management, board, and other functions or committees as needed.Collaborate with PacificSource and local providers and Medical Directors to establish guidelines, policies, criteria and procedures for review and determination related to clinical practices, claims, care coordination, reimbursement, provider credentialing, and quality management.As assigned, research new technologies, new medications, and other evolving healthcare products and services to help determine a standard of care and standard of coverage. Assist with drafting and revision of policies relating to such issues.Provide visibility and maintain positive physician relationships as a representative of PacificSource, in local and regional medical community.As assigned, be specifically responsible for hiring, staff development, coaching, performance reviews, corrective actions, and termination of employees. Provide feedback to direct reports including regular one-on-ones and performance evaluations.Provide clinical expertise to the Quality / Risk Department, including QIMs, NCQA, HEDIS, and CAHPS Programs.As appropriate, develop annual department budgets. Monitor spending versus the planned budget throughout the year and take corrective action where needed.Responsible for process improvement and working with other departments to improve interdepartmental processes. Monitor key performance indicators and identify improvement opportunities.

Supporting Responsibilities:

Meet department and company performance and attendance expectations.Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.Perform other duties as assigned.

SUCCESS PROFILE

Work Experience: MD or DO required. Three to five years as an Assistant Medical Director or Medical Officer of a health insurance plan, or equivalent work experience strongly preferred. Experience in an integrated healthcare system a plus. Significant senior management policy and decision-making experience, including developing and implementing management best practices preferred.

Education, Certificates, Licenses: Board certification preferred. State license can be in any of the four states (MT, ID, WA, OR), or be willing to apply for state licensure in one of these four states.

Knowledge: Comprehensive knowledge of business principles and techniques of administration, organization, and management to include an in-depth understanding of the key business issues that exist in the healthcare industry. These include, but are not limited to quality improvement including, Lean methodology, healthcare economics, personnel administration, financial and cost analysis, trends in the healthcare industry. Excellent understanding of all areas of medical conditions, treatment, and care. Excellent understanding of the insurance industry and risk factors, and how they relate to the PacificSource organization. Remain current in the medical field. Basic computer skills required. In-depth knowledge of local clinical communities, along with in-depth knowledge of Oregon Health Plan preferred. Ability to read and comprehend Spanish a plus.

Competencies

Authenticity

Building Organizational Talent

Coaching and Developing Others

Compelling Communication

Customer Focus

Empowerment/Delegation

Emotional Intelligence

Leading Change

Managing Conflict

Operational Decision Making

Passion for Results

Environment:

Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 10% of the time.

Skills:

Accountable leadership, Business & financial acumen, Empowerment, Influential Communications, Situational Leadership, Strategic Planning

Our Values

We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:

We are committed to doing the right thing.We are one team working toward a common goal.We are each responsible for customer service.We practice open communication at all levels of the company to foster individual, team and company growth.We actively participate in efforts to improve our many communities-internally and externally.We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.We encourage creativity, innovation, and the pursuit of excellence.

Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.