Engineering director Jobs in Stockton, CA

The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.

What You Will Be Doing :

Under limited supervision, the Medical Director is responsible for providing clinical oversight of the Health Plan's utilization, quality, pharmacy, and credentialing and health equity functions in a manner that ensures the delivery of quality, cost effective healthcare, supports organization objectives, and meets contractual, accreditation and regulatory requirements. The position supports the grievances and appeals team with clinical oversight of grievances and quality of care investigations and resolutions. Work is varied and highly complex and requires a moderate to high degree of discretion and independent judgment.

Our Vision :

Continuously improve the health of our community.

Our Mission :

We provide healthcare value and advance wellness through community partnerships.

Essential Functions :

• Provides clinical leadership for medical management functions; assists subordinate managers in resolving medical claims review, grievances, appeals, and other medical management issues.
• Works closely with the Deputy CMO (DCMO) to identify medical service issues that have an impact on plan benefits and their administration, develop action plans and monitor results.
• Identifies and analyzes and assists in identifying and analyzing care and quality issues and trends; makes recommendations based on findings; develops and implements agreed upon changes.
• Provides clinical expertise needed to effectively and efficiently resolve complex, controversial, and / or unique administrative circumstances.
• Conducts clinical reviews and makes UM decisions for prior, concurrent, and retro authorizations, and appeals; approves / denies or offers medical alternatives according to HPSJ's medical review criteria for both Medi-Cal and Dual Eligible Special Needs Plan (DSNP) members.
• Conducts reviews of grievances and quality of care issues for both Medi-Cal and DSNP members : identifies opportunities for improvement and works with both internal and external stakeholders to improve care and services.
• Provides expertise and guidance for activities related to improving quality and health equity metrics.
• Establishes and maintains working relationships with providers, provider organizations and other stakeholders that supports contracting, provider relations, marketing and other organizational goals and objectives.
• Collaborates with leadership to ensure medical compliance with internal, regulatory and accreditation requirements.
• Provides medical expertise and direction for clinical policies, procedures, and programs.
• Serves on Quality Improvement & Health Equity Committee, Peer Review and Credentialing Committee, Grievance and Appeals Committee, Clinical Operations Committee and Physician Advisory Committees; serves on other committees as required.
• Represents HPSJ in a manner that promotes a positive image of HPSJ in the community.
• Assists with development of corporate and department budgets and metrics.

What You Bring :

Knowledge, Skills, Abilities and Competencies

Required

Preferred

What You Have :

Education and Experience

Required

Preferred

Licenses, Certifications

Required

What You Will Get : HPSJ Perks :

We are an equal opportunity employer and diversity is one of our core values. We believe that differences including race, ethnicity, gender, sexual orientation, and other characteristics, will help us create a strong organization that is sensitive to the needs of those we serve. Employment decisions are made on the basis of qualifications and merit.

HPSJ provides equal employment opportunities to employees and applicants for employment and prohibits discrimination based on color, race, gender (including gender identity and gender expression), religion (including religious dress and grooming practices), marital status, registered domestic partner status, age, national origin (including language use) or ancestry, physical or mental disability, medical condition (including cancer and genetic characteristics), sex (including pregnancy, childbirth, breastfeeding or related medical condition), genetic information, sexual orientation, military or veteran status, political affiliation or any other characteristic made unlawful by applicable Federal, State or local laws. It also prohibits unlawful discrimination based on the perception that anyone has these characteristics or is associated with anyone who has or is perceived to have these characteristics.

Important Notice : This job description is not a contract between HPSJ and the employee performing the job. The duties listed in the job description may be changed at the discretion of HPSJ, and HPSJ may request the employee to perform duties that are not listed on the job description.