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Senior Medical Director

Denver

Pinnacol Assurance does just one thing, and does it better than anyone: provide caring workers’ compensation protection to Colorado employers and employees. And while we may be a little biased, we believe that our work shapes communities and changes lives.

We have big hearts and love big ideas. We’ve been around for more than  100 years, but don’t let that fool you. Pinnacol is committed to taking care of Colorado employers and workers in the most innovative ways. We celebrate continuous improvement, new ideas, compassion, teamwork, integrity and excellence.

What you’ll do:

The Senior Medical Director works collaboratively with Operations Leadership to develop and maintain quality and medical management strategies and network programs. Will be responsible for implementation and evaluation of clinical programs, including but not limited to, value-based programs and incentives, care outcomes, central utilization review and program integrity.

What you can expect:

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 
ADDITIONAL DUTIES:
  • Other duties as assigned
WORK ENVIRONMENT / PHYSICAL ACTIVITIES:
  • Mainly office environment. Must be able to attend meetings, industry and community events requiring before/after hours and travel.

What you need to be successful:

  • Comprehensive knowledge of managed care processes and systems.
  • Extensive experience overseeing effective Utilization Review/Authorization Program.
  • Thorough knowledge of Workers’ Compensation laws, industry regulations, licensing and accreditation issues.
  • Current unrestricted Colorado Board of Medical Examiners License (MD or DO) Current State of Colorado Division of Workers’ Compensation Level I or II Physician
  • Accreditation ABMS or AOA Board Certification in related specialty
  • Master’s Degree in business, health information, public administration, information systems, insurance or other related field is preferred
  • Minimum of five years of clinical experience with at least two years in a supervisor or Medical Director position, which includes experience in administration of insurance and/or managed care programs.

We can’t do our work without people like you.
Our employees are extraordinary and committed to making a difference. Here’s some of the ways we show our appreciation.

  • Our benefits go beyond the basics. You’ll get to choose from diverse benefit offerings for medical, dental and vision.
  • We care about each other. We enjoy a positive, collaborative work environment. We are hard workers and high performers.
  • We love who you are. We’re committed to creating a culture that deeply values differences, where everyone feels like they belong.
  • Take a day (or 20!) off. Enjoy 20 paid days off your first full year plus 9 paid holidays.
  • Take care of yourself. Sign up for unique wellness programs, including on-site, company-paid fitness facilities and classes
  • Get your learning on. We promote a learning culture to help you master your current job and cultivate the skills of the future through a variety of on-site, online, and off-site professional development opportunities.
  • Give back and get paid. Through our employee volunteer program, Pinnacol in Action, employees receive paid time off to volunteer with Colorado nonprofits.
  • Share in our success. This role is eligible to participate in Pinnacol’s annual key employee performance plan with a 25% target.

When we find the right person, we try to put our best foot forward with an offer that excites you. We consider what you’d like to be paid, the skills and experience you bring, what similar jobs pay in the Denver area and make sure there’s equal pay for equal work among those you’ll be working with. The compensation amount for this role is targeted at $329,800 to $356,300. Final offer amounts are determined by multiple factors including your experience and expertise and may vary from the amounts listed above.

Want to love your work? Apply today!

Pinnacol is committed to working with and providing reasonable accommodations to applicants with disabilities. To request assistance with the application process, please email recruiting_team@pinnacol

This posting will close 15 days after being published: April 30 2025

 

Salary Range

$329,800 - $356,300 USD

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