- Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit.
- Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities.
- Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services.
- Supports effective implementation of performance improvement initiatives for capitated providers.
- Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members.
- Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.
- Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership.
- Oversees the activities of physician advisors.
- Utilizes the services of medical and pharmacy consultants for reviewing complex cases and medical necessity appeals.
- Participates in provider network development and new market expansion as appropriate.
- Assists in the development and implementation of physician education with respect to clinical issues and policies.
- Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components.
- Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care.
- Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality.
- Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment.
- Develops alliances with the provider community through the development and implementation of the medical management programs.
- As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues.
- Represents the business unit at appropriate state committees and other ad hoc committees.
- Medical Doctor or Doctor of Osteopathy, board certified preferable in a primary care specialty (Internal Medicine, Family Practice, Pediatrics or Emergency Medicine).
- The candidate must be an actively practicing physician.
- Previous experience within a managed care organization is preferred.
- Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is preferred.
- Experience treating or managing care for a culturally diverse population preferred.
- Board Certification through American Board Medical Specialties.
- Current state medical license without restrictions.
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