Medical Director, Pediatrics bei CenCal Health

Description

Central Coast Salary Range:  $281,107 -$449,771

Candidates for this position must reside on the Central Coast (Ventura, Santa Barbara, San Luis Obispo, Monterey and Santa Cruz Counties) or be willing to relocate to the area upon hire. As a community-facing role, a local presence is essential to effectively engage with and serve our community. Please note that relocation assistance may be available.

Job Summary

The Medical Director, Pediatrics provides strategic leadership and clinical oversight for the plan’s pediatric related programs and services, serving as subject matter expert in General Pediatrics.  Under the direction of the Chief Medical Officer (CMO) and in collaboration with the Department Directors, this position provides support and consultation for pediatric utilization management, behavioral health, case management, quality of care, and regulatory functions involving pediatric members. The position provides direct clinical evaluation and resolution for service requests within the Whole Child Model Program (WCMP) including California Children’s Services (CCS) benefits. 

1. Clinical Leadership & Oversight
2. Clinical Review & Decision-Making
3. Regulatory Compliance, Appeals & Grievances
4. Provider & Stakeholder Relations
5. Quality Improvement & Program Development
6. Collaboration & Committees
7. Other Responsibilities

Duties & Responsibilities

The Medical Director ensures the delivery of high-quality, cost-effective healthcare to pediatric members, supports the health plan’s operational and strategic objectives, and maintains compliance with all applicable state and federal regulations.  This role requires extensive clinical expertise, sound judgement, and a high degree of discretion in managing complex and sensitive matters.

1. Clinical Leadership & Oversight

• Provides clinical leadership for medical management functions, including utilization management (UM) and case management (CM), ensuring alignment with clinical criteria and organizational goals.
• Actively participates in complex case management team meetings for Whole Child Model Program (WCMP) participants.
• Provides clinical direction on medical eligibility and benefits in compliance with state and county regulations.
• Offers medical consultation and clinical expertise to nurse case managers, clinical staff, and Medical Therapy Program Units.
• Provides clinical oversight in developing and implementing care management strategies and opportunities.
• Collaborates closely with the Chief Medical Officer (CMO) and other Medical Directors to identify and address medical service issues impacting plan benefits, develop action plans, and monitor progress.

2. Clinical Review & Decision Making

• Conducts clinical reviews and renders utilization management decisions for prior, concurrent (hospital), and retrospective authorizations, as well as appeals.
• Approves, denies, or recommends modifications based on CenCal Health’s medical review criteria, and engages with providers as needed via phone or in person for peer-to-peer consultation.
• Reviews enrollee deaths, high-cost durable medical equipment requests, and preauthorization denials.
• Evaluates and approves requests for air transport, organ transplants, and inpatient rehabilitation.
• Advises the Pediatric WCMP team on Numbered Letters related to California Children’s Services (CCS) conditions, medications, and medical procedures.
• Collaborates with the Pharmacy team to assess the clinical appropriateness of medication utilization.

3. Regulatory Compliance, Appeals & Grievances

• In-depth understanding of standard healthcare contract components, compliance requirements, and audit, control, and monitoring processes, with the ability to implement and sustain effective oversight mechanisms.
• Ability to identify, analyze, and apply key metrics and performance models to drive evidence-based decision-making and program improvement.
• Participates in the plan’s Appeals & Grievances process, under the direction of the Chief Medical Officer and in collaboration with the Clinical Quality Team and other medical directors, to review and resolve member appeals and grievances as set forth through our established policies and procedures.

4. Provider & Stakeholder Relations

• Serves as the WCMP physician liaison with Special Care Centers and other clinical partners.
• Develops and maintains relationships with CCS providers, provider organizations, and other stakeholders to support provider contracting, education, and organizational objectives.
• Collaborates with the Provider Services Department to train providers on WCMP standards, policies, and procedures, including care coordination, medical home models, and family-centered care.
• Builds partnerships to promote quality outcomes, efficient resource utilization, and provider engagement.

5. Quality Improvement & Program Development

• Identifies and analyzes quality issues and trends, makes recommendations based on findings, and implements approved changes.
• Engages in quality improvement activities related to WCMP and CCS, including the development of performance measures and reporting.
• In conjunction with the Clinical Quality team, participates in population health initiatives to improve pediatric outcomes.
• Maintains focus on process improvement, operational efficiency, and service excellence for all pediatric related services and functions.

6. Collaboration & Committees

• Collaborates across departments to support integrated care delivery and alignment with health plan objectives.
• Participates in committees that address the care and services for pediatric members and as requested by the Chief Medical Officer, which may include but is not limited to the Quality Improvement Health Equity Committee (QIHEC), the Compliance Committee, the CalAIM Steering Committee, and the Physician Advisory Board. Serves as chair of the Pediatric Clinical Advisory Committee (PCAC).
• Works closely and collaboratively with UM/CM and behavioral health (BH) teams and other internal stakeholders to support coordinated, high-quality pediatric care.

7. Other Responsibilities

• Provides on-call coverage as needed for post-stabilization care services.
• Performs other duties as assigned to meet organizational and program needs.
• This position currently has no direct reports but maintains close collaborative relationships with all medical management teams.

Qualifications

Knowledge/Skills/Abilities

• CCS-approved/paneled pediatrician or pediatric specialist with in-depth clinical expertise in pediatric care.
• Extensive knowledge of managed care principles and practices, including utilization management, case management, and discharge planning, particularly within government-sponsored programs such as Medi-Cal and Medicare.
• Strong understanding of healthcare delivery systems and the unique needs of pediatric and medically underserved populations.
• Comprehensive understanding of population health concepts and social determinants of health, with the ability to apply these principles to improve outcomes for high-risk or vulnerable groups.
• Knowledge of healthcare economics, quality improvement methodologies, and data-driven approaches to measure and enhance care performance.
• Thorough knowledge of standard healthcare contract components, compliance requirements, and audit, control, and monitoring processes.
• Ability to develop, implement, and sustain effective regulatory oversight and compliance mechanisms.
• Skilled in identifying, analyzing, and applying key metrics and performance indicators to support evidence-based decisions.
• Demonstrated ability to develop, execute, and monitor strategic and operational plans that align with organizational goals and values.
• Proven experience supervising and mentoring staff, fostering a collaborative, high-performance team environment.
• Strong project management skills, including the ability to manage multiple priorities and initiatives effectively.
• Excellent collaboration skills with the ability to work effectively across interdisciplinary teams and with external partners, including government agencies and community organizations.
• Exceptional interpersonal skills and the ability to build and maintain productive working relationships at all organizational levels.
• Proficient in team building, facilitation, problem-solving, and conflict resolution.
• Outstanding verbal and written communication skills, with the ability to communicate complex information clearly, concisely, and persuasively.
• Strong presentation and public speaking abilities, with skill in tailoring messages to diverse audiences.
• Commitment to excellence in customer service and stakeholder engagement.
• Proficient in Microsoft Word and Excel, with strong analytical and documentation skills.
• Ability to manage confidential and sensitive information with discretion and integrity.
• Proficient in spoken and written English.

Education & Experience

• MD degree from an accredited medical school.
• Successful completion of an ACGME-accredited pediatric residency program and/or pediatric sub-specialty fellowship.
• Board certification in general pediatrics or a pediatric sub-specialty.
• A minimum of three (3) years of clinical experience in managed care/utilization management.
• At least three (3) years of supervisory experience in a healthcare setting is preferred.
• Experience in Utilization Management/Case Management within a managed care setting is preferred.
• Unrestricted license to practice medicine in California issued by the State Board of Medical Examiners, meeting the Health Plan’s credentialing and re-credentialing requirements.
• MPH or MBA is desirable.
• Experience with CCS administration (Utilization Management/Case Management) is preferred.