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Medical Director

Location:

Apply on line at http://www.alohacare.org/Careers/Default.aspx

 

The Company:

 

AlohaCare is a local, non-profit health plan serving the Medicaid and Medicare dual eligible population.  We provide comprehensive managed care to qualifying health plan members through well-established partnerships with quality health care providers and community-governed health centers. Our mission is to serve individuals and communities in the true spirit of aloha by ensuring and advocating access to quality health care for all. This is accomplished with emphasis on prevention and primary care through community health centers that founded us and continue to guide us as well as with others that share our commitment. As Hawaii’s third-largest health plan, AlohaCare offers comprehensive prevention, primary and specialty care coverage in order to successfully build a healthy Hawaii.

 

The Culture:

 

AlohaCare employees share a passion for helping Hawaii’s most underserved communities.  This passion for helping and caring for others is internalized and applied to our employees through a supportive and positive work environment, healthy work/life balance, continuous communication and a generous benefits package.

 

AlohaCare’s leadership empowers and engages its employees through frequent diversity, recognition, community, and educational events and programs. AlohaCare has a strong commitment to support Hawaii’s families and reinforces a healthy work/home balance for its employees. Because AlohaCare values honesty, respect and trust with both our internal and external customers, we encourage open-door, two-way communication through daily interactions, employee events and quarterly all-staff meetings. AlohaCare’s comprehensive benefits package includes low cost medical, dental, drug and vision insurance, PTO program, 401k employer contribution, referral bonus and pretax transportation and parking program.

 

These employee-focused efforts contribute to a friendly, team-oriented culture which is positively reflected into the communities we serve.

 

The Opportunity:

 

The Medical Director is a key member of the health services team that strives toward outstanding member quality of care and safety.  The Medical Director supports quality improvement, proper utilization of health service benefits under MedQUEST and Medicare, implementation of the Care Model with its risk stratified care coordination, achievement of Medical Loss Ratio initiatives, completion of regulatory compliance, and fulfillment of NCQA standards.  Responsible to build external relationships that strengthen AlohaCare’s provider network.  The Medical Director participates in multi-disciplinary committees, ad hoc working groups, and interdisciplinary team conferences across the organization.  The Medical Director is a contributor of operational and strategic planning.  Reports to the Chief Medical Officer.

 

 

 

Primary Duties and Responsibilities:

 

Quality Improvement

Collaborates with the Director of Quality Improvement and team on attaining goals in quality performance for any one or more of the following:  Pay-For-Performance for providers, MedQUEST health plan quality incentive program, HEDIS, Star Rating, and CAHPS.

Collaborates with the Sr. Manager of Population Health in developing and implementing Performance Improvement Projects (PIP) and EPSDT programs;

Facilitates communication, coordination, and collaboration related to behavioral health quality projects;

Co-Chairs the Corporate Quality Improvement Committee;

Attends and participates in the advisory Board Quality Committee.

Utilization Management:

Provides daily medical oversight of AlohaCare’s utilization management related to physical services, behavioral health services, formulary drugs, and Long Term Services and Support;

Is responsible for and participates in making final determinations of complex or problematic prior authorization requests based on medical necessity;

Assists in overseeing the development and maintenance of medical policies that state the guidelines and criteria for the utilization of physical or behavioral health services;

Collaborates with pharmacists in addressing issues involving under/over utilization, drug prior authorizations, medication adherence, provider services, and safety;

Develops and maintains skill in using web-based tools or other systems for medical decision-making and actionable analytics;

Integration of Behavioral and Physical health

Collaborates with other internal leaders – for example, quality, utilization management, pharmacy, care coordination, provider relations, claims -- to strategize, plan and implement program(s);

Participates in BH-PH related activities such as IDTs, provider development, telehealth, MedQUEST meetings.

Actively contributes to the achievement of Medical Loss Ratio initiatives as related to utilization management, quality improvement, and other aspects of medical expense management

General Clinical Activities:

Participates in regular interdisciplinary team rounds regarding hospital and SNF/ICF discharge coordination and transition of care;

Responds to medical issues raised by service coordinators, care coordinators, or service/care navigators;

Collaborates in the planning and implementation of initiatives that meet current NCQA standards or comply with MedQUEST and Medicare regulations;

Assists in the processing of ADRC (Aid to Disable Review Committee) submissions to MedQUEST for added benefits under the Aged Blind and Disabled program;

Participates in relevant aspects of MedQUEST and Medicare Audits;

Is assigned membership to standing or ad hoc committees, such as the Practitioners Advisory Committee, Pharmacy & Therapeutics Committee, Credentials Committee, and Safety Committee;

Provides feedback regarding mandatory reports of health services to MedQUEST or CMS.

Interacts with the provider community – such as hospitals, emergency departments, skilled nursing facilities, long term care institutions, group or solo providers – building relationships, identifying opportunities, and educating providers about AlohaCare.

Develops and nurtures relationships with community health centers (Federally Qualified Health Centers), independent providers, and institution-based medical leaders.

Participates in strategic planning that involves clinical-related areas as well as organizational wide efforts.

Assists in scheduling medical director coverage, as well as participating in the on-call schedule on weekends and holidays.

Participates in disaster planning, drills and response.  

Responsible to maintain AlohaCare’s confidential information in accordance with AlohaCare policies, and state and federal laws, rules and regulations regarding confidentiality.  Employees have access to AlohaCare data based on the data classification assigned to this job title.

Requirements:

 

Doctor of Medicine or Osteopathy(MD/DO)

Five or more years of clinical practice in direct patient care

Experience in medical leadership of clinical services, programs, or provider organizations;

Three or more years of health plan experience;  

Experience in multi-disciplinary collaboration and team work

Public speaking and professional presentation skills

Analytic skills and skill at using data systems

Proficient in Microsoft professional suite (Word, Excel, PowerPoint)

Preferred Requirement:

 

Previous experience as a Medical Director

Experience in a managed care organization

Licensure/Certification:

 

State of Hawaii unrestricted licensure to practice medicine

Board Certification

Mental, Physical and Environmental Demands:

 

Indoor and occasional outdoor working conditions.

No environmental hazards.

Sedentary Work: Exerting up to 20 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects.  Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time.  Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

Requires on-island vehicular travel & occasional inter-island travel with overnight stays, as well as working occasional evenings and weekends.

 

 

 

 

 

 

 

AlohaCare is committed to providing equal employment opportunity to all applicants in accordance with sound practices and federal and state laws.  Our policy prohibits discrimination and harassment because of race, color, religion, sex (including gender identity or expression), pregnancy, age, national origin, ancestry, marital status, arrest and court record), disability, genetic information, sexual orientation, domestic or sexual violence victim status, credit history, citizenship status, military/veterans status, or other characteristics protected under applicable state and federal laws, regulations, and/or executive orders.

Contact Information

Contact: Josie Gesteuyala, AlohaCare
Email: jgesteuyala@alohacare.org
Phone: 808-973-6339

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University of Hawai‘i Alumni