Senior Medical Director

Acumen in strategic and operational planning to develop and implement innovative clinical initiatives and programs that optimize injured workers’ quality of care, outcomes, experience; and policyholder cost efficacy and value.

• Leverages data-driven insights to plan and execute clinical strategies targeting improvement that are consistent with best practices in workers compensation management, state and federal regulations.
• Provide meaningful strategic input to senior management, clinical staff, Physician Advisors, regulators and network providers concerning changes in accreditation standards, implications of proposed legislature, utilization management criteria, clinical guidelines, delivery system trends and related issues.
• Stays current with and develops strategies to implement leading-edge health technology and informatics. Leverages lean management principles to foster an environment of continuous learning, improvement, innovation and experimentation.
• Will be responsible for implementation and evaluation of clinical programs, including but not limited to, value-based programs and incentives, care outcomes, utilization management and program integrity.

In conjunction with the AVP and Director of Medical Operations, responsible for the development, maintenance and evaluation of provider network quality and outcomes. Identify opportunities for continuous improvement in the performance of the network and develop processes to monitor improvement.

• Assumes leadership responsibilities and actively participates as Chair of both the Credentialing and Quality of Service Committee (CQSC) and the Network Affiliation Committee (NAC) to develop and ensure network quality and consistency according to established standards.
• Responsible for the planning, directing and monitoring of the Physician Advisor program including training, performance evaluation, management oversight, sharing of best practices and supervision.
• Examines, analyzes and reports on network and non-network data trends and outcomes. Recommends and implements initiatives that address quality, cost, outcomes, experience and operations issues.
• Provides clinical expertise and direction that supports appropriate utilization management, and application of evidence-based practices.
• Actively supports and communicates network policies and procedures to providers and other medical organizations and works to ensure effective implementation and compliance of policies and procedures.
• Develops and improves provider relations across Colorado communities and actively participates in outreach efforts to expand the network and improve access to quality care for injured workers and policyholders.

Develops and maintains strong provider, business and community relationships. Works collaboratively across the organization building strong relationships and influence to improve operational performance and improvement.

• Actively engages with physicians to problem-solve, educate, coach and otherwise ensure quality and cost effective outcomes. Collaborates with physicians and provider groups on targeted issues.
• Able to build credibility and establish trust within all levels of the organization, providers, agencies, and policyholders.
• Listens, interprets, negotiates and consensus builds to successfully resolve issues and build support across diverse stakeholder groups.
• Bridges claims and medical management operations to network and providers on complex issues identifying and resolving pain points, and identifying opportunities for continuous improvement
• Consults, engages and serves as a resource to claims and medical management operations, safety and worksite wellness disciplines.
• Serves as a liaison on behalf of Pinnacol to legislative, regulatory and legal communities
• Provides education, advocacy, information and professional development to internal staff, Physician Advisors, provider groups, policy-makers and the community.
• Represents the Company in medical affairs through active involvement in county and state medical societies, medical specialty societies, medical professional organizations and select special engagements.
• Represents the Company on a local, regional and /or national level by participating in pertinent research, studies or authorship of reports/papers for scientific or trade journals, and/or speaker or guest lecturer/instructor at meetings, conferences, etc. and /or public response as necessary regarding medical matters and managed care issues relevant to Pinnacol.
• Regularly authors and presents various network educational communications, articles and research insights to non-clinical audiences positioning Pinnacol as a leading edge business, industry and community innovator
• Translates data analytics and complex clinical materials into compelling communications in formal and informal settings
• Review complex workers compensation cases and provide oral and written opinions on the case(s).

Develop and Lead Central Utilization Review Program at Pinnacol

• Work with Med Ops UR Manager and Claims team on planning and implementation of the utilization review (UR) program, including budget and ROI projections, workflows, training materials, technical resources and configurations.
• Development of strategic communications related to Pinnacol’s network performance and UR programs to foster external stakeholder buy-in
• Responsible for the evolution of our Centralized Utilization Review program (also, emulating URAC standards) requires oversight of medical director to bridge the world of medicine and insurance, applying DOWC medical treatment guidelines and working collaboratively with Medical Director of the DOWC 

WORK ENVIRONMENT / PHYSICAL ACTIVITIES:

• Mainly office environment. Must be able to attend meetings, industry and community events requiring before/after hours and travel.