Medical Director – Pittsburgh, PA
Physicians – are you looking for a purposeful career that will allow you to broadly improve care for the medically underserved? This organization offers this – and so much more…career growth is unlimited here.
Assist the VP of Clinical Programs to direct and coordinate the physician component of the utilization management functions for the PA market.
Great opportunity to influence your peers in the medical community.
· Provides medical leadership for utilization management activities and medical review activities pertaining to utilization review, quality assurance, medical review of complex, and controversial or experimental medical services such as transplants utilizing the services of consultants
· Performs case reviews and appeals for all health plans.
· Assists VP of Clinical Programs in planning, 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.
· 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.
· Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment
- Medical Doctor or Doctor of Osteopathy, board certified preferably in a primary care specialty (Internal Medicine, Med/Peds, Family Practice, Pediatrics or Emergency Medicine) or other specialty familiar with Medicare patients.
-Previous experience within a managed care organization is preferred.
- Experience treating or managing care for a culturally diverse population preferred.
- Must be an actively practicing physician – willing to practice a few hours weekly (your preference)
- Board Certification through American Board Medical Specialties.
-Current PA medical license without restrictions.