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
Available to the CHC-MCO's medical staff for consultation on referrals, denials, complaints and problems.
Directly involved in the CHC-MCO's recruiting and credentialing activities
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.
Knowledge of due process procedures for resolving issues between Network Providers and the CHC-MCO administration, and between participants and the CHC-MCO, including those related to medical decision making and utilization review.
Available to review, advise and take action on questionable hospital admissions, Medically Necessary days and all other medical care and medical cost issues.
Directly involved in the CHC-MCO's process for prior authorization or denying services and is available to interact with Providers on denied authorizations.
Knowledge of current peer review standards and techniques.
Knowledge of risk management standards.
Directly accountable for all Quality Management and Utilization Management activities.
Oversees and is accountable for: (a) referrals to the Department and appropriate agencies for cases involving quality of care and services that have adverse effects or outcomes; and (b) the processes for potential Fraud, Waste, and Abuse audit, investigation, review, sanctioning and referral to the appropriate oversight agencies.
Required skills and experiences:
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.
License/Certificates: Board Certification through American Board of Medical Specialists. Current state medical license without restrictions.