D-SNP Clinical Advisor bei CenCal Health

Description

Central Coast Hourly Range: $135.15 - $216.24 Per Hour

​​​​​​​While candidates from anywhere in California are welcome to apply, there is a strong preference for those who reside on the Central Coast (Ventura, Santa Barbara, San Luis Obispo, Monterey and Santa Cruz Counties). This role may offer opportunities for remote work; however, familiarity with and proximity to our local customers is valued.

Job Summary

Under the direction of the Chief Medical Officer, the D-SNP Clinical Advisor is responsible for:

1. Providing clinical expertise in the implementation of the D-SNP Model of Care (MOC).

2. Providing clinical guidance and consultation to the Chief Medical Officer, Medical Directors, and D-SNP clinical teams regarding tactical execution of the D-SNP Program including but not limited to utilization, quality, care management, and grievances/appeals.

3. Serving as a strategic clinical advisor to the D-SNP Program, supporting the development, implementation, and continuous improvement of CenCal Health’s D-SNP.

4. Other duties as assigned.

Duties and Responsibilities

1. Providing clinical leadership and contribution in the implementation of the D-SNP Model of Care (MOC) with duties including but not limited to:

• Serving as a subject matter expert of D-SNP clinical operations in the training and development of CenCal Health’s medical directors and clinical staff during the pre-launch phase and launching of our D-SNP line of business, CenCal CareConnect.

• Providing consultation, advice and support for the D-SNP Model of Care implementation, ensuring alignment with regulatory requirements and clinical best practices.

• Advising on care coordination strategies, health risk assessments, individualized care plans, and clinical documentation standards to support MOC compliance.

• Participating in the development of staff training and education programs related to the MOC, including training for internal teams and delegated entities.

• Consulting on policies and procedures related to D-SNP operations, care coordination, utilization protocols, and clinical documentation to ensure consistency with the MOC.

• Providing expertise and clinical insight into the development of effective Interdisciplinary Care Team (ICT) meetings.

• Participating in medical director meetings that address the management and care of D-SNP members or that include training, advising, or guiding CenCal Health’s medical directors in the execution of D-SNP clinical pathways.

• Collaborating with our internal teams as they develop care plans that address the unique medical, behavioral, and social needs of D-SNP members, improving both individual and population-level health outcomes.

• Collaborating with the CMO, Medical Directors, and D-SNP Clinical teams to assess provider feedback and design or adapt clinical processes in response to provider needs.

• Partnering with Health Service’s training sponsor to serve as a clinical subject matter expert in the development and delivery of internal D-SNP training initiatives, particularly those involving the Model of Care and other content requiring clinical expertise.

2. Providing clinical guidance and consultation to the Chief Medical Officer, Medical Directors, and D-SNP clinical teams regarding tactical execution of the D-SNP Program including but not limited to:

• Delivering insight and expertise to clinical teams regarding the design and execution of utilization management, quality, care management, and grievances/appeals clinical pathways for CenCal CareConnect members.

• Guiding the design and refinement of clinical workflows that support interdisciplinary care teams, person-centered care planning, care transitions, behavioral health integration, and addressing social determinants of health.

• Collaborating closely with Health Services’ leaders to establish clinical pathways and operational standards that optimize health outcomes for D-SNP members.

• Providing clinical expertise in CenCal Health’s monitoring and evaluation of D-SNP quality measures, including HEDIS, STAR ratings, CAHPS, and NCQA accreditation standards.

• In collaboration with the Chief Medical Officer, providing clinical expertise to the Pharmacy team in the build-out and integration of the Part B benefit, specifically physician administered drug (PAD) claims.

• Advising the CMO and Directors on identified potential risks and mitigation strategies to maintain service quality on implementation of the D-SNP program.

• In collaboration with the CMO, medical directors, and D-SNP clinical team, offering clinical expertise to our Case Management team to review complex cases, evaluate care outcomes, and ensure that D-SNP patients receive appropriate, timely, and cost-effective care.

• Supporting and providing expert opinion regarding the implementation of population health strategies, including preventative care, chronic disease management, and the reduction of healthcare disparities, to improve overall health outcomes for D-SNP members.

3. Serving as a strategic clinical advisor to the D-SNP Program, supporting the development, implementation, and continuous improvement of CenCal Health’s D-SNP, with duties including but not limited to:

• Serving as the principal clinical advisor for the D-SNP product to the CMO and D-SNP clinical teams, contributing strategic clinical insight from design through implementation and performance evaluation.

• Staying current on federal and state policy updates, CMS and DHCS guidance, and emerging best practices in Medicare-Medi-Cal integration.

• Supporting and consulting on efforts to ensure that the D-SNP product complies with CMS and DHCS requirements and delivers high-quality, person-centered care to dual-eligible members enrolled in both Medicare and Medi-Cal.

4. Other duties as assigned.

Qualifications

Knowledge/Skills/Abilities

Required:

• Thorough knowledge, understanding, and experience with government-sponsored healthcare programs including Medi-Cal and Medicare.

• Extensive knowledge of managed care principles and practices, particularly regarding utilization management, appeals and grievances, case management, and discharge planning.

• Deep understanding of healthcare, economic, and other factors affecting Medi-Cal and Medicare populations, providers, and underserved communities in Santa Barbara, San Luis Obispo Counties, and surrounding areas.

• Maintains a focus on process improvement and organizational efficiency in all projects.

• Strong ability to identify, implement, monitor, and analyze key metrics and models, and recommend effective interventions based on findings.

• Expertise in audit, control, and monitoring processes.

• Understanding of population health concepts and social determinants of health.

• Exceptional facilitation, problem-solving, and conflict resolution skills.

• Strong collaboration skills with a proven ability to foster a team-oriented work environment, maintain high-performance teams, and organize people and resources towards a common goal.

• Excellent interpersonal skills, capable of establishing and maintaining effective relationships with individuals at all levels. Skilled in team building and consensus development.

• Exceptional oral and written communication skills, with the ability to communicate clearly, persuasively, and professionally with diverse individuals and groups.

• Strong presentation skills, including the ability to tailor content for specific audiences and engage large groups effectively.

• Demonstrated ability to align with and promote organizational values, integrating them into management practices and encouraging staff to do the same.

• Strong customer service orientation.

• Excellent project management skills.

• Proficient in Microsoft Word and Excel.

• Proficient in spoken and written English.

• Ability to handle confidential information with discretion and integrity.

• Displays ability to quickly adapt to changing requirements, special assignments and workload re-prioritization.  Openness to different and new ways of doing things; willingness to modify one’s preferred way of doing things.

• Ensuring that one’s own and others’ work, and information are complete and accurate; carefully preparing for meetings and presentations; following up with others to ensure that agreements and commitments have been fulfilled.

• Follows through and is accountable for all actions. Demonstrates integrity and values in behavior and decisions.

Education and Experience

Required:

• Current California Medical License issued by the Medical Board of California. Unrestricted license to practice medicine in California, issued by the State Board of Medical Examiners, and meeting the Health Plan’s credentialing and re-credentialing requirements.

• Board certification by an accredited specialty body.

• MD/DO degree from a US accredited medical school.

• Successful completion of a residency program accredited by the American Council of Graduate Medical Education (ACGME) or the American Osteopathic Association (AOA).

• A minimum of three to five (3-5) years of clinical experience in the practice of medicine.

• At least 3-5 years of experience in Medi-Cal and Medicare Utilization Management/Case Management within a health plan, IPA, or similar medical management organization.

• Ability to travel and meet in person on occasion at the CenCal Health Offices in Santa Barbara/SLO, to conduct essential business functions when required.

• Attendance at all expected meetings. Maintains professional demeanor in meetings by being prepared, on-time, and contributing to the essential business at hand.