The Medical Director will be responsible for managing health plan medical costs and assuring appropriate health care delivery for plans and members. They will be responsible for leading the organizations efforts to achieve excellence in healthcare affordability, quality, member experience, and improved population and member outcomes. They will serve as a clinical leader for teams dedicated to concurrent review, prior authorization, case management and clinical coverage review.
– Share the health plan’s passion for evidence-based medicine and be comfortable applying evidence-based guidelines. Collaborate with other senior leaders in efforts that enhance the quality of care delivery, improve outcomes, and improve value delivered to our members.
– The Medical Director can expect to perform the following functions:
– Support pre-admission review, utilization management, concurrent and retrospective review process and case management.
– Provide professional leadership and direction in the utilization/cost management (UM) and clinical quality improvement (QI) of the health plan, as measured by benchmarked UM and QI goals.
– Work collaboratively as a clinical resource to other plan functions that interface with medical management such as provider relations, member services, benefits, claims management, etc.
– Ensure members receive safe, effective, equitable, efficient, timely and patient-centered health care services within their health plan benefits.
– Carry out medical policies at the health plan consistent with NCQA and other regulatory bodies.
– Participate and/or chair clinical committees and work groups as assigned.
– Review medical care, medical service, and pharmacy requests against established clinical guidelines and make approval and denial determinations in accordance with evidence-based standards, organizational policies and procedures, and regulatory requirements.
– Identify potentially unnecessary services and care delivery settings, and recommend alternatives, as appropriate.
– Review appeals of medical and pharmacy denials against established clinical guidelines and make approval and denial determinations in accordance with evidence-based standards, organizational policies and procedures, and regulatory requirements.
– Identify opportunities for corrective action plans to address issues and improve plan and network managed care performance.
– Collaborate with Provider Networks and Medical Director team in creating and maintaining programs that incentivize providers to achieve selected utilization/cost and quality outcomes.
– Participate in the retrospective review and analysis of plan performance from summary data of paid claims, encounters, authorization logs, compliant and grievance logs, and other sources.
– Provide periodic written and verbal reports and updates as required in the Quality Management Program description, the Annual QI Work Plan.
– Assure plan conformance with legal and regulatory requirements; support NCQA qualification activities, including site visits and response to accrediting and regulatory agency feedback.
– Participate in risk management, claims administration, pharmacy utilization management, catastrophic case review, outreach programs, HEDIS reporting, site visit review coordination, triage, nutrition service review, provider orientation, credentialing, profiling, etc.
– Conduct quality improvement and outcomes studies as directed by the state and federal regulatory agencies, the Quality Management Committee, Medical Advisory Committee, Peer Review Committee, and management.
– Support grievance process, as led by Chief Medical Officers, ensuring a fair outcome for all members.
– Monitor member and provider satisfaction survey results and implement changes as needed to increase satisfaction and assure that satisfactory relationships are maintained between network and plan participants.
– May be asked to chair various health plan committees, such as Quality Management subcommittees on Peer Review or Credentialing.
– Promote wellness and ensure programs of prevention, education and outreach to members and providers consistent with the company’s Mission, Ambition, and Values
– Perform and oversee in-service staff training and education of professional staff.
– Contribute to the development of strategic planning for existing and expanding business; recommend changes in program content in concurrence with changing markets and technologies.
– Participate in key marketing activities and presentations, as necessary, to assist the marketing effort.
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