The Medical Director leads healthcare initiatives in partnership with the Health Plan and MSO leaders with specific attention to medical management, quality initiatives, and clinical oversight. Serves as a clinical advisor and educator to ensure clinical quality and efficacy of patient care.
Collaborates with the Health Plan Chief Medical Officer (CMO) and MSO leadership to provide oversight of clinical programs to support and meet utilization management and quality goals with accountability to achieve medical expense and quality performance targets. Responsible for physician review of utilization / medical and quality management to include, but not limited to: prior authorization, acute and post-acute reviews, retrospective reviews, case management, appeals, judicial hearings, claims, pharmacy, quality of care, peer review, and credentialing.
Provide clinical knowledge and review of regulatory deliverables to ensure high quality and detailed completion with financial sign-off and approval when appropriate. Provides support as the clinical subject matter expert for internal and/or external audits by regulatory agencies. Represents the Plan in the healthcare community with clinical guidance regarding legislative and regulatory issues related to medical policies and coverage benefits.
Identify trends in patient treatment data and facilitates interaction with care teams, clinical leaders, and other leaders to translate clinical, quality, and financial data into actionable strategies to achieve performance goals. Designs and executes clinical action plans that align with operational and network strategy. Supports other departments in a consultative role requested.
MD or DO with an active, unrestricted state medical license required; board certification in medical specialty required
Minimum of five (5) years of clinical experience required
Minimum of two (2) years of managed care experience strongly preferred
Proficiency with managed care environment with a philosophy of collaboration and team work
Excellent verbal and written communication skills with the ability to build consensus
Ability to process map and manage large projects to successful completion