Summary of PositionManage the daily clinical operation and administration of a Medical Management Department or function to support improved utilization results across the spectrum of medical specialties. Provide clinical leadership both internally and externally. Serve as an essential liaison among Senior Management, Plan staff, contracted providers, vendors, and membership to promote and improve communication and operations areas of medicine including Internal Medicine, OB/GYN, Psychiatry, Ambulatory Medicine, Emergency Medicine and Radiology. Carry out assigned programs to ensure the delivery of quality medical care to the EmblemHealth membership and compliance with contractual obligations and standards; assist in the development and implementation of new policy and programs as needed. Maximize operational effectiveness and oversight of assigned functions, ensuring regulatory compliance and accreditation with Department of Health, Department of Insurance, CMS, NCQA, and URAC standards.
Principal Accountabilities- Manage use of medical resources for inpatient and outpatient services including Internal Medicine, OBGYN, Neurology, Surgery, Pediatrics, Emergency Medicine or Psychiatry.
- Determine medical appropriateness through the application of clinical criteria; perform case management review; and participate in the clinical appeals process.
- Sole authority and responsibility for issuing clinical adverse determinations based on medical necessity.
- Conduct medical rounds, attend Medical Director meetings and participate in the inter-rater reliability process.
- May also perform peer clinical reviews as needed.
- Establish and maintain continuity in the planning, development and implementation of policies, operational processes, workflows required to execute organizational strategies and to assure consistency in process application throughout Care Management.
- Validate and monitor adherence to implemented policies, procedures, workflows and processes: identify, recommend and implement improvement initiatives accordingly.
- Generate methods to develop and improve the overall delivery and performance of the department.
- Implement process improvements in a timely manner.
- Deal effectively with and lead others throughout Company structure.
- Support other areas in implementing cross-departmental changes.
- Make sound decisions based on all available data.
- Determine medical appropriateness through the application of clinical criteria and perform case management review.
- Demonstrate familiarity with high-risk populations, community settings and care of medical patients.
- Anticipate and identify key source information to analyze problems clearly and determines creative solutions.
- Provide thought leadership to articulate and help build an effective and efficient medical delivery program.
- Identify trends, problems and opportunities, conduct root cause analysis.
- Implement action plans in an effective and efficient manner aimed at promoting goals/resolving barrier issues.
- Strive to improve efficiencies of key operational areas.
- Assist with contract negotiations as necessary.
- Represent Care Management in interdepartmental committees designed to meet organizational goals.
- Develop annual goals and oversight of assigned department/function.
- Support Senior Medical Directors in communications with internal and external organizational goals; ensure a high level of customer satisfaction (members, vendors, providers, regulators, accreditation agencies, peers and employees).
- Chair or participate on committees as requested.
- Regular attendance is an essential function of the job.
- Perform other duties as assigned or required.
Qualifications- MD or DO degree. Board certification is required
- Active New York or Connecticut license or certification to practice medicine without restriction required
- 10+ years of relevant, professional work experience
- 5+ years of clinical practice
- Administrative experience on a hospital committee, in a medical group or for an insurer
- Knowledge of clinical practice of medicine, health care delivery systems, utilization methods and treatment protocols
- Knowledge and understanding of managed care principles, industry evolution, physician reimbursement, and human resource management
- Experience conducting evidence-based treatments in group and individual modalities, especially for psychiatric treatment
- Considerable independent decision making with physicians, members, subordinates, other departmental leaders and external vendors, regulatory and accreditation agencies
- Excellent communication skills (verbal, written, presentation, interpersonal); tact and diplomacy sufficient to successfully carry out the above duties and responsibilities
