Position Purpose: Direct and coordinate the medical management, quality improvement and credentialing functions for the assigned business unit based on, and in support of the strategic plan, establishing the strategic vision and attendant policies and procedures.
- Serves as clinical advisor to and educator of medical management staff making sure correct clinical judgment is applied to all medical management determinations.
- Oversees internal medical review guidelines to ensure clinical integrity and compliance and acts as a resource for staff members throughout the operation.
- Coordinates with other departments, the responses needed to address regulatory accreditation concerns pertaining to medical management issues
- Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services.
- Facilitates the achievement of the Medical Management Program goals through an effective health services delivery system.
- Responsible for physician review and oversight of all potential adverse determinations including pre-certifications/prior authorizations, concurrent review and appeals/retrospective review.
- Responsible for HEDIS improvement and strategy.
- Actively participates in the auditing process of medical management processes and corrective action team projects for medical management
- Achieves utilization, cost management and quality goals.
- Participates and advises in the development of corporate medical policies for UM, pharmacy, and new technology
For Home State Health Plan only – responsible for the sufficiency and supervision of the health plan provider network
Additional responsibilities for Pennsylvania Health & Wellness
Ensure the provision of LTSS in home and community based settings is provided in accordance with the requirements
Serves as Liaison to the Chief Medical Officer for Department of Human Services
Must be available to medical staff for consultation on referrals, denials, complaints and grievances and other problems that may arise such as Quality of Care investigations
Responsible for recruiting and credentialing activities
Has knowledge of due process procedures for resolving issues between network Providers and health plan administration, and between participants and Health Plan, including those related to the medical decision making and utilization review
Responsible for direct involvement in the MCO's process for prior authorizing or denying services and is available to interact with Providers on denied authorizations
Oversee referrals to the Department and appropriate agencies for cases involving quality of care that have adverse effects or outcomes
Oversee Fraud and Abuse investigations, review, sanctioning and referral to the appropriate oversight agencies
Education/Experience: Medical Doctor or Doctor of Osteopathy, board certified in a specialty recognized by the American Board of Medical Specialists. Volunteer patient care required. Previous experience as Medical Director is preferred. Master’s degree in Business Administration, Public Health, Healthcare Administration or related field preferred.
For Pennsylvania Health & Wellness: Must have knowledge of risk management standards and current peer review standards and techniques. Must be familiar with local standards of medical practice and nationally accepted standards of practice, including those for LTSS and with “most integrated setting” requirements under the ADA
License/Certificates: Board Certification through American Board of Medical Specialists. Current state medical license without restrictions.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
Primary Location: USA-Pennsylvania-Harrisburg
Organization: Pennsylvania Health & Wellness