– Share the health plans 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 companys 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.