Position Purpose: Direct and coordinate the medical management, quality improvement, and pharmacy functions for assigned business unit based on the strategic plan
- Oversee cost containment and medical quality improvement activities. Manage medical review activities pertaining to pharmacy review, quality assurance, and medical review of complex, controversial, or experimental medical services
- Lead strategic planning for all clinical initiatives and facilitate all clinical issues related to medical care
- Recruit, coordinate and oversees activities of staff medical directors, physician advisors, and community medical directors. Recruit and utilize the services of medical and pharmacy consultants for reviewing complex cases and medical necessity appeals
- Identify utilization studies and evaluate adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components. Identify clinical quality improvement studies to reduce unwarranted variation in clinical practice in order to improve the quality and cost of care.
- Responsible for business unit physician committees including committee structure, processes, and membership.
- Direct the development, implementation, operation maintenance, and control of all essential medical services
- Responsible for all state required initiatives related to medical affairs, including successful HEDIS outcomes and NCQA accreditation
- Develop and implement pay for performance programs
Education/Experience: Medical Doctor or Doctor of Osteopathy degree. Board certification in a primary care specialty (Internal Medicine, Family Practice, Pediatrics or Emergency Medicine) and previous experience as Medical Director in a managed care organization. MBA preferred. 5+ years post licensure experience as a senior clinician and leader with responsibility for clinical standards, quality management, and clinical supervision in a managed care organization. 3+ years of clinical practice must be documented. Experience treating or managing care for a culturally diverse population preferred. Experience with government programs preferred.