This job works closely with all divisions and departments within the corporate structure to provide clinical consultation and support, compliance with accepted medical standards, and practitioner/providereducation. The incumbent is an integral part of the utilization management team to ensure delivery of quality and cost–effective care, member/provider satisfaction, and quality outcomes. A key component of this role is to review denials of care based on medical necessity. The incumbent acts as a liaison for Gateway with practitioners/providers through ongoing communications and monitoring of services utilized. The incumbent assists operations/programs to comply with accreditation and regulatory standards, including but not limited to NCQA, Delaware Medicaid and medical Assistance, CMS, Gateway corporate and medical policies.
- Review utilization management cases and communicate the decisions to the member and provider.
- Collaborate with Gateway staff and physician advisory committees for development of Gateway policies, procedures and special projects.
- Active participation in establishing Gateway’s medical policy, and support established policy as it relates to the care management process and communications with practitioners.
- Become familiar with the principles of continuous quality improvement and apply them in clinical and management functioning.
- Work as a team member coordinating the needs of multiple practitioners and providers across the network.
- Attend meetings as appropriate, including medical director meetings, QI committee and subcommittees, as assigned.
- Serve as a resource for information and consultation on the issues related to utilization management, clinical services and medical affairs, including such issues as case management, disease state management programs and health risk assessments.
- Provide consultation to the care and case management staff, offer advice and assistance in achieving resolution of problem cases, and actively support care and case management activities.
- Intervene as the spokesperson with local practitioners/providers to resolve care and case management issues and participate in the development of long-term strategies to create cost-effective medical care.
- Establish or maintain communication with practitioners and providers and become knowledgeable about their practice patterns in order to identify those factors of quality that define the best practices and once defined, helping them with continuous quality improvement
- Develop understanding of current hospital and physician payment methodologies, and how they impact utilization incentives in the provider community.
- Establish effective working relationships with hospital, physicians and managers in order to bring about desired outcomes by affecting modifications in the practice patterns for both inpatient and outpatient services.
- Monitor the clinical program initiatives in achieving desired quality and financial objectives.
- Attend corporate QI committee meetings and selected subcommittee meetings and report on clinical initiatives and network management activities.
- Become familiar with the principles of the TQM/CQI processes.
- Regionally supervise and/or collaborate the activities/directives of the QI operations staff and committees.
- Grievances and Appeals – Assist in the evaluation and resolution of grievances and appeals of patients, providers, and hospitals.
- Maintain familiarity with applicable State and Federal Quality Assurance Regulations to ensure the organization’s compliance with them.
- Develop expertise in the external requirements for quality leadership, including NCQA accreditation, and the creation of an accurate HEDIS data set.
- Perform other duties as assigned by the Chief Medical Officer and as assigned or requested.
- Medical staff leadership experience, significant prior experience in health care management roles, and involvement with formal quality and/or utilization management programs are required
- 5 years of experience as a primary care physician or other valuable medical expertise and current knowledge of the clinical practice concerns and issues
- Board certification in a primary medical specialty and a current, unrestricted PA medical license is required
- MBA, MPH, MMM or other advanced education in business or public health
- Proven ability to manage a project in order to accomplish previously agreed upon goals within a reasonable time period and through the use of developed organization and leadership skills
- Excellent communication and public speaking skills, well-developed interpersonal skills, and ability to interact effectively with members, practitioners/providers, colleagues, and local State and Federal agencies
- Professional UR/QI training and certification
Foster a reprisal free environment to promote open and constructive communication
All Medicare contractor position descriptions are subject to the Centers for Medicare and Medicaid Services (CMS) security requirement to classify positions as to their sensitivity levels. These levels relate to the impact that the position has on access to Medicare beneficiary protected health information and/or financial information. The designations are high, medium and low sensitivity with each designation having specific background investigation criteria applied to them. The reinvestigation is required to be conducted at least every five years for each position.