8725 Henderson Road Tampa, FL 33634
Client: Large Fortune 500 Health Insurance Company
Location: Based in Florida, however, can work Remotely
Medical License Eligible: FL, GA, NC, SC, KY, HI, MO, NJ, MI, AZ
Pay Rate: $119.62/hr
SHIFT: Thursday - Sunday (evenings Thursday and Friday / Saturday and Sunday days)
- Oversees clinical direction of medical services and quality improvement functions at the health plan level.
- Provides medical management leadership for the health plan and, as applicable, manages all major clinical and quality program components under health plan operations.
- Oversees medical coordination required for effective utilization and quality management of the health plan network.
- Functions as medical leadership for effective care integration of pharmacy operations, utilization/case/disease Management activities, quality improvement activities, and provider relations functions.
Key Duties and Responsibilities
- Collaborates with the organization’ s senior leadership to ensure medical compliance with all customer, regulatory, and accreditation requirements for clinical services.
- Provides current medical expertise and direction for clinical policies, procedures and programs.
- As required by business and operational priorities, establishes professional working relationships with providers and provider organizations to support the development of the highest possible provider partnerships.
- Manages day-to-day quality improvement and medical management activities.
- Establishes and is accountable for health plan utilization, OS applications and quality outcomes.
- Assures all internal and vendor medical review activities conform to company protocols, customer requirements, and professional standards.
- Ensures adherence to assigned budget accountability.
- Works closely with other medical directors and clinical services staff to attain and/or maintain compliance with company, customer, accreditation and regulatory requirements.
- Provides clinical expertise needed to effectively and efficiency resolve complex, controversial and/or unique administrative circumstances.
- Provides clinical guidance for sales, marketing, legal, regulatory affairs, financial, operational, and related business activities.
- As requested and needed, provides expert medical education, consultation, and supervision for the clinical staff.
- Provides medical leadership for development and attainment of the organization’ s goals.
- Support provider relations and risk contracting through education, provider visits and problem resolution
- Collaborates with corporate care management to establish and implement clinical programs to support and meet care management goals
- Manages the application of all clinical aspects of the Credentialing Program, Credentialing Committee and Peer Review activities at the state level.
- Shares responsibility for quality improvement and accreditation initiatives in the assigned market(s)
- Develops value propositions for clinical programs through quantitative analytics, ROI and evidence-based data
- Initiates dialogue with providers, as necessary, to resolve differences in opinions concerning utilization management. Reviews and makes determinations regarding provider appeals.
- Ensure compliance with federal, state and NCQA standards
- Oversees provider education regarding pharmacy, utilization, quality improvement and responsible health care expenditures to improve clinical outcomes
- Establishes and maintains relationships with key stakeholders in partnership with the market leadership
- Provides medical accountability in fulfilling the company’ s compliance with customer audits and reports, and accreditation surveys.
- Performs other duties as assigned.
- A Doctor in Medicine (MD) or D.O. from an accredited school of medicine recognized by national medical regulatory bodies in the United States Required
- 5+ years of experience in direct patient care Required
- Substantial experience and expertise in the development of medical policies, procedures and programs Required
- Demonstrated success implementing utilization and quality improvement strategies /techniques and experience with physician behavior modification Required
- Qualifications to perform clinical oversight for the services provided by the health plan to include but not limited to: Education, training or professional experience in medical or clinical practice Preferred
- Past participation in a managed care UM committee Preferred
- Experience as required by state contract. For the SC Healthy Connection Prime Demonstration, experience in geriatrics or adult medicine and experience/training with coordinating care for adults with multiple chronic conditions as required by state contract Required
- An unrestricted and current license to practice medicine in the state of employment (or the ability to obtain one) Required
- Board Certification Required
- Ability to communicate and make recommendations to upper management Advanced
- Ability to effectively present information and respond to questions from families, members, and providers Advanced
- Ability to create, review and interpret treatment plans Advanced
- Demonstrated leadership skills Advanced
- Ability to work in a fast paced environment with changing priorities Advanced
- Demonstrated interpersonal/verbal communication skills Advanced
- Demonstrated organizational skills Advanced
- Demonstrated ability to deal with confidential information Advanced
- Ability to represent the company with external constituents Advanced
- Demonstrated negotiation skills Advanced
- Ability to influence internal and external constituents Advanced
- Ability to remain calm under pressure Advanced
- Must be able to apply medical knowledge and principles to business challenges in order to achieve significant member, business, and quality outcomes Advanced
- Must be detail-oriented and have a “ hands-on” approach Advanced
- Clear understanding of the managed care field and managed care operating components, with emphasis on clinical management of health services, particularly within an integrated managed care model Advanced
- Clear understanding of regulatory systems and processes that affect managed care health system Advanced
- Microsoft Excel Intermediate Required
- Microsoft Word Intermediate Required
- Microsoft PowerPoint Intermediate Required
- Microsoft Visio Intermediate Required
- Microsoft Outlook Intermediate Required