Job Description

San Francisco Health Plan is committed to providing high-quality care for low-income San Franciscans and supporting the provider safety net. We leverage our resources to support the triple aim: improved population health, improved quality of care, and improved affordability. The individual in this position is the Plan's primary UM physician, leads our complex medical case management program and provides physician expertise to the health services department: clinical operations (UM: inpatient and outpatient), health improvement (HEDIS, practice improvement, care management IT systems, member incentives, community-based care coordination) and pharmacy (including PGY 1 pharmacy residency, medication therapy management program). The Associate Medical Director also plays an important role with key health plan initiatives, such as the implementation of a care management system designed to improve coordination of care and achieve better clinical outcomes, creating clinical criteria, and evaluating UM strategies to improve efficiency.

Depending on the individual, this role can be either a full time or a part time opportunity, with remote work capability. However, the person must be local to the San Francisco Bay Area.

WHAT YOU WILL DO

Provide clinical decision-making and support:

• Work collaboratively with nurses, social workers, and coordinators to ensure high quality, coordinated care.
• Attend inpatient rounds and provide clinical guidance on medical necessity decisions, including contacting attending physicians to discuss patients when appropriate.
• Assume primary responsibility for utilization management and pharmacy decisions: determining medical necessity based on established criteria, interpreting benefits and limitations, consulting with providers as appropriate. Actively participates in Utilization Management Committee
• Investigate and resolve potential quality incidents and determines their appropriateness for review by the Physician Advisory Committee.
• Review appeals and provides second opinions regarding medical necessity
• Review clinical grievances and active participant in Grievance Review Committee
• Call physicians to discuss management of members, related to pharmacy and UM authorizations, inpatient care, and/or high-dose pain management, focusing on evidence, best practices and medical necessity.

Provide clinical input for programs:

• Work with Director of Pharmacy to ensure an appropriate formulary (addressing safety, choice, and cost-containment) and improve quality of pharmacy reporting.
• Perform site visits to high-volume prescribers, providing counsel for cost-effective and safe prescribing.
• Assist in developing and revising policies to support utilization management activities, including criteria and guidelines for appropriate use of services, clinical practice guidelines, and treatment guidelines
• May serve on the Quality Improvement Committee, Pharmacy and Therapeutics Committee, or the Practice Improvement Program Advisory Group.
• Provides clinical guidance related to systems implementations (such as new care management IT integration systems)

WHAT YOU WILL BRING

• MD/DO degree from an accredited program, with active, unrestricted California medical license. Board certified required.
• A current CA license to practice without restriction.
• 5+ years of clinical experience.
  • Previous managed care experience preferred.
• Experience and facility with health information technology and clinical data analysis.
• Ability to manage challenging conversations with professional peers related to medical case review; supportive of managed care strategies.

ABOUT US

Established in 1997, San Francisco Health Plan (SFHP) is a an award winning, managed care health plan whose mission is to provide affordable health care coverage to the underserved low and moderate-income residents in San Francisco county. SFHP is chosen by eight out of every ten San Francisco Medi-Cal managed care enrollees and its 145,000+ members have access to a full spectrum of medical services including preventive care, specialty care, hospitalization, prescription drugs, and family planning services. SFHP was designed by and for the residents it serves, and takes great pride in its ability to accommodate a diverse population that includes young adults, seniors, and people with disabilities.

San Francisco Health Plan is an Equal Opportunity Employer (EOE) M/F/D/V
Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.