Medical Director

Tampa, FL 33634

Posted: 06/14/2019 Category: Healthcare Job Number: 28671

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)

Summary
  • 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.

Requirements:
  • 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

Skills
  • 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

Technology
  • Microsoft Excel Intermediate Required
  • Microsoft Word Intermediate Required
  • Microsoft PowerPoint Intermediate Required
  • Microsoft Visio Intermediate Required
  • Microsoft Outlook Intermediate Required

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