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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.

The Senior Medical Director is responsible for leading improvement in clinical development strategies, and execution of clinical programs including implementation of the strategic plan through strategic cascades and metrics, and the oversight of operational activities of the medical directors. This role leads a clinical team with assigned medical directors and reports to the Chief Medical Officer (CMO). The Senior Medical Director role interfaces and collaborates with health services project management and leadership within PacificSource to carry out the initiatives of the strategic plan and CMO. The Senior Medical Director may interface with appropriate governmental and regulatory agencies to influence, understand, and implement policy. The Senior Medical Director is expected to actively engage with the provider community in support of PacificSource\'s strategic and operational goals. The Senior Medical Director is a community leader with all Health Services VPs and the CMO.

Essential Responsibilities:

Lead clinical utilization review efforts (e.g. lengths of stay, appropriateness of service, intensity of service, medical necessity, and experimental/investigational services) on a prospective, concurrent, or retrospective basis coordinating with the medical director and utilization management operational team.

Oversee pre-authorizations review, claims, and other cases involving pre- or post-service requests for coverage.

Provide expertise and medical interpretation with respect to claims adjudication, underwriting, contract language, disputes and appeals, policy drafts, and care management issues.

Lead the efforts of 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.

Oversee the development of systems of care with providers for management of appropriate care and case management related to acute, catastrophic, and long-term cases.

Provide clinical and operational expertise for physical and behavioral health care, quality, case management, risk, network, and utilization management, as well as health promotion, disease management, pharmacy review, grievance and appeals, quality incentive programs, and revenue cycle management.

Lead Cost Containment Committees, work to include anticipation of trends impacting global budget, and proactively address those trends in line with Triple Aim goals.

Manage internal operations and participates in activities related to the cost of care and cost and use functions with certain defined Provider Partners and in Coordinated Care Organization (CCO) Special Operations Committees.

Within the clinical care domain, manage all aspects of data and analytics to deliver actionable analytics to provider partners, with aim to achieve lower cost care with better quality and greater customer satisfaction.

Provide leadership in decision making for i clusion and integration or continuation of new clinical services within Health Services.

Lead the work of applying process improvement techniques to analyze, identify, and implement changes to workflow, staff, and organizational structure that improve operational efficiency and effectiveness in the areas of authority of the Senior Medical Director.

Work with the Chair Quality Assurance Utilization Management and Pharmacy and Therapeutics Committees as needed. Prepare agendas, collaborate with the committee, research topics presented to the committee, and follow through on committee actions.

Review and manage appeals and grievances. Lend expertise to the preparation of cases for appeals, presentation, or further external review. Assist in reviewing Pharmacy denials and redeterminations.

In collaboration with CMO and other Medical Directors interface with the Oregon Health Authority to influence, track, and implement Oregon Health Plan clinical policy; including active participation in relevant committee work e.g. Quality Health Outcome Committee.

Develop annual department budgets. Monitor spending versus the planned budget throughout the year and take corrective action where needed Responsible for hiring, staff development, coaching, performance reviews, corrective actions, and termination of