Primary Purpose:
Establish and maintain strong working relationships with physicians affiliated with the network. Promote the MSO and IPA missions, visions, and values. Actively lead physicians to provide quality, efficient, humane, timely, and cost-effective care and services to patients as it pertains to medication treatment. Define quality and utilization goals and initiate and lead quality improvement projects. Provide active pharmaceutical leadership to personnel supporting quality improvement, utilization management, and credentialing activities. Support Administrator in contracting, cost management, customer satisfaction, and other management and service-related issues as they pertain to medication/pharmaceuticals. Evaluate network physician performance based on objective outcomes and provide feedback to individual physicians so that they modify ineffective practices, improve service, maintain patient access, and address clinical performance issues as needed. Promote and provide opportunities for physicians to network and receive education on clinical care and treatment options.
Principal Duties and Responsibilities:
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Will attend 75% of all required meetings and, in the event of an anticipated absence, will send a network physician representative.
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Assist in preparation of meeting agendas that include instructive cases and educational elements.
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Actively work to improve physicians' knowledge base and provide instruction to elevate providers' care and service performance.
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Implement Utilization Management and Quality Improvement Programs and monitor assurance of compliance with contracted health plans and other regulatory agencies.
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Monitor physician practice patterns for under- and overutilization of medication treatments.
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Maintain direct involvement in management of high-cost medication treatments.
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Handle referral requests in a timely manner and ensure that medical decisions are objectively based on clinical effectiveness and evidence-based considerations.
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Provide Administrator and Case Manager(s) with timely interpretation of medical benefits and render recommendations as needed.
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Review, recommend, and support denials of service and payment when appropriate and ensure decisions are based on contemporary evidence-based references.
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Actively review technology assessments regarding experimental and/or clinical trial procedures and therapeutics with the contracted health plans.
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Be familiar with health plan bulletins and policy statements of coverage and be able to access other medical reference sources.
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Monitor, evaluate, and manage pharmacy utilization and costs and use these results to educate and actively engage network physicians to achieve clinically effective and cost-effective outcomes.
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Actively participate in planning and implementation of risk management activities.
- Work closely with Quality and Utilization departments to identify risk exposures, rectify them, and actively participate in corrective actions or interventions as required.
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Understand and facilitate network compliance with health plan and regulatory criteria and standards, including but not limited to NCQA, CMS, and DMHC. Be familiar with new regulations and lead modification of network practices to comply with new regulations or law as needed.
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Define and implement evidence-based practice guidelines, monitor their effectiveness and provide objective feedback and guidance to providers in regard to medication treatment plans.
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Assist the case managers and nurse practitioners with medication adherence and medication reconciliation as needed.
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Provide appropriate and effective directives for local providers to achieve optimal outcomes and benchmarks.
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Attend PCP meetings, as needed, to educate, inform, and resolve primary care issues in regard to medication treatment plans.
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Represent the organization at external/internal meetings to enhance delivery of care, utilization management, and quality of care issues as needed
Personal Requirements:
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Must maintain a current California Pharmacist license without restrictions.
- Must maintain professional liability coverage.
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Requires extensive knowledge of managed care, including utilization and case management and quality processes.
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Act in a professional manner when interacting with physicians, IPA staff, the public.
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Maintain high-quality medical care standards.
Position Performance Criteria:
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Sets appropriate priorities to meet IPA goals and objectives including but not limited to:
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Consistently renders prudent and sound decisions
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Meets required timeframes
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Adheres to IPA policies and procedures
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Demonstrates knowledge of Health Plan guidelines.
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Demonstrates knowledge of federal, state, NCQA, and health plan regulatory requirements and approved criteria guidelines.
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Ensures consistency in the application of the utilization process.
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Maintains knowledge of new legislation.
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Demonstrates cost savings without sacrificing quality of care.
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Consistently demonstrates professional work ethic, collegial interaction with others, and reliability, while contributing to a positive work environment.
