Inland Empire Health Plan

Senior Medical Director - Policy & Outcomes

10801 Sixth Street, Rancho Cucamonga, CA 91730

On-site · Full-time

First seen by offpeak October 6, 2026

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Overview

What you can expect!

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience!

Reporting to the Vice President of Health Services, the Senior Medical Director Policy & Outcomes (Sr. Medical Director - P&O) is responsible for the strategic oversight of IEHP Medical Policies and clinical leadership around member health outcomes. The Sr. Medical Director - P&O oversees the day-to-day operations as it relates to developing, executing, leading and updating guidelines, policies, clinical pathways, and communications enabling effective health outcomes, as well as effective health plan performance as per DHCS, DMHC, CMS, and CCA clinical requirements. This leader serves as the accountable medical leader for clinical activities related to key activities including quality management, grievance and appeals, and appropriate clinical resource stewardship. The Sr. Medical Director - P&O also works in partnership with the appropriate cross functional departments to monitor the impact of policy outcomes through regular reporting, metrics, initiatives, and other improvement activities. This position is responsible for supporting regulatory audits for all its relevant domains

Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Additional Benefits

Perks

IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more.

Competitive salary
Hybrid schedule
State of the art fitness center on-site
Medical Insurance with Dental and Vision
Life, short-term, and long-term disability options
Career advancement opportunities and professional development
Wellness programs that promote a healthy work-life balance
Flexible Spending Account – Health Care/Childcare
CalPERS retirement
457(b) option with a contribution match
Paid life insurance for employees
Pet care insurance

Key Responsibilities

Lead the development and execution of creating and/or updating medical policies and procedures to align with health plan regulatory requirements. Ensure guidelines and clinical pathways are updated with best practices, along with appropriate downstream connections to utilization management, population health, and other compliance and regulatory activities

Serve as clinical lead for efforts to promote appropriate evidence based clinical practices to improve member outcomes and support responsible stewardship of resources across all lines of business

Lead clinically, through strong partnerships with other departments for activities related to member outcomes, quality improvement, grievance and appeals, healthcare resource stewardship, and network corrective action plans. Develop and increase collaborative relationships with internal departments. Assure interdepartmental collaboration and communication with key business departments, including, but not limited to, compliance, member experience, provider relations, and claims

Serve as a liaison with providers, county public health partners and oversight agencies as assigned

Monitor network performance proactively to ensure adherence to policy standards. Develop and implement appropriate internal initiatives to address any issues impacting member outcomes

MAJOR RESPONSIBILITIES

Co-leadership with the Sr. Medical Director of Health Servies to advance IEHP’s Mission, Vision and Values. Work in partnership with the Senior Medical Director focusing on UM to coordinate daily huddles, develop work schedules, adherence to department metrics and KPIs, and training of medical staff

Manage medical directors, as well physician reviewers, working in the domains of policy, outcomes, grievances and appeals, quality management and clinical guideline development

Provide clinical direction to the Health Service team and act as a resource to all IEHP departments responsible for providing or coordinating clinical services to IEHP members

Direct, implement, and/or enhance medical policy, internal policies, and job aids as it relates to member safety and quality management activities, clinical guideline development, delegation and oversight, credentialing, peer review, and compliance related activities

Ensure medical decisions are rendered by qualified medical personnel, unhindered by fiscal or administrative management, with timely and appropriate use of UM criteria and guidelines

Direct clinical and workflow training for medical directors and physician reviewers within their oversight

Ensure medical personnel of the Plan and its delegates follow IEHP policies, protocols and rules of conduct consistent with the values of IEHP

Identify gaps in policies or activities relating to member outcomes and implement strategic, effective solutions

Serve as a primary point of contact for clinical, quality and performance issues for medical directors at delegated IPAs, as well as for providers in the IEHP direct network

Support other departments as needed to ensure timely completion of member grievances and appeals as required for regulatory compliance

Provide clinical leadership, support and/or guidance including, but not limited to, the following areas:

Inpatient claims reviews as needed

Utilization review

Member case management

Provider incentive programs

Credentialing, Peer Review and Member Safety Subcommittees

Audit preparation and participation

Projects involving total cost of care initiatives

Monitor, track, and trend data for appropriate utilization, and develop key initiatives to mitigate any unfavorable trends (e.g., over or under-utilization) using evidence based best practices

Reviews State mandated benefits to ensure IEHP is in full compliance through its policies

Perform any other duties as required to ensure Health Plan operations and department business needs are successful

Qualifications

Education & Requirements

Seven (7) years of post-residency experience in a recognized medical specialty or practice, which must have included at least (3) years of medical administrative experience and a minimum of five (5) years of managed care or health plan leadership experience with proven track record of leading high performing physician teams
Experience working with clinical practice guidelines and evidenced based criteria sets
Has exposure to working with regulatory agencies
- Medical Director for an IPA, medical group, or CA HMO highly desirable. Medical specialty/practice experience preferably in the state of California
Doctorate of Medicine from an accredited institution required
Certification by one (1) of the American Specialty Boards required
Completion of an accredited residency program required. Possession of an active, unrestricted, and unencumbered Physician’s and Surgeon’s Certificate issued by the State of California required
- (A physician certified in a state other than California may be employed prior to receipt of California certification provided that an application for a California physician and surgeon’s certificate is filed in the state of California prior to date of appointment.)

Key Qualifications

Expert level knowledge and thorough understanding of:
- Managed Care principles
- Administrative practices and procedures (including but not limited to: credentialing and risk management, rules regulations, policies, and standards related to managed care)
- Principles of effective supervision and organization; methods, techniques, practices, principles, and literature in the broad field of medical sciences
- The principles of medical practice in a variety of settings (inpatient, outpatient, subacute, and similar items)
- Federal and state regulatory requirements, including CMS, DHCS, DMHC, CCA, NCQA, and associated clinical policy and compliance standards
- Cost-of-care levers, utilization patterns, total cost of care initiatives, and financial drivers within value‑based environments
- Managing complex grievance and appeals issues, ensuring compliance, timeliness, and defensible clinical rationale
- Familiarity with local healthcare organizations and/or local practice experience preferred
Advanced proficiency in:
- Communication skills (written and verbal), both clinical and operational, for cross-functional collaboration across departments
- Policy development skills
- Analytical and data interpretation skills; problem solving
- Presentation skills
- Microcomputer applications such as Microsoft Word, Excel, and Access
Demonstrated ability to:
- Maintain clinical independence, ensuring medical decision-making is free of inappropriate administrative or financial influence
- Be an assertive communicator
- Be an effective leadership of other physicians and clinical staff
- Have a track record of leading with accountability
- Possess a strong attention to detail and be organized
- Drive and execute outcomes and improvements
- Lead through change, navigating evolving regulatory landscapes, new clinical guidelines, and operational shifts

Start your journey towards a thriving future with IEHP and apply TODAY!

Work Model Location

This position is on a hybrid work schedule. (Monday & Friday - remote, Tuesday - Thurs onsite in Rancho Cucamonga, CA.)

Travel within California

Pay Range

USD $280,841.60 - USD $393,182.40 /Yr.

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