POSITION SUMMARY/ OBJECTIVE
Provides medical oversight and expertise in appropriateness and medical necessity of healthcare services provided to Plan members, targeting improvements in efficiency and satisfaction for patients and providers, as well as meeting or exceeding productivity standards. Educates and interacts with network and group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management.
- Knows, understands, incorporates and demonstrates the Florida Community Care’s Mission, Vision and Values in behavior, practice, and decisions.
- Provides the direct clinical direction for ensuring the high quality and efficient care of the plan.
- Provides the review and assessment of 701B and enrollees’ plan of care, working with other care managers of the integrated care team (ICT) to ensure the desired outcome of enrollee is consistent with Florida Medicaid statute.
- Serves as the primary physician in the performance of and leadership of utilization management and quality of care functions.
- Provides clinical leadership for and oversight of care management, population health, quality, patient safety, risk management, and utilization initiatives implemented.
- Provides leadership over and oversees key operational aspects of quality, care management, care coordination, and process improvement initiatives.
- Works collaboratively with care management staff and leadership to minimize unnecessary duplication of resources.
- Conducts special projects as requested by Chief Medical Officer.
- Performs all other duties as assigned.
REQUIREMENTS FOR ALL POSITIONS
All employees shall meet specified training programs including Compliance/Privacy Regulations, and attend at a minimum one (1) hour of Compliance/Privacy educational training annually, as required by Florida Community Care (FCC).
All employees shall meet Risk Management Regulations, and attend at the minimum one (1) hour of Risk Management education and training within the first thirty (30) days of employment and as required by law or Florida Community Care; and, for that non-physician in clinical direct care delivery services, annually thereafter.
All employees if duly licensed in the State of employment, and said license is part of requirement of their position with Florida Community Care, shall maintain in good standing and current state licensure.
All employees are required to maintain confidentiality, protect privacy, comply with PHI regulations, and report violations.
POSITION RESPONSIBILITIES AND ACCOUNTABILITY
Core duties and responsibilities include the following. Other duties may be assigned.
- Facilitates conformance to Florida Medicaid, the contract that Florida Community Care has with the Agency for Health Care Administration, AAAHC accreditation body, and other regulatory requirements.
- Reviews quality referred issues, focused reviews and recommends corrective actions.
- Conducts prospective, concurrent and retrospective reviews of clinical cases, medical claims review and clinical appeals as required.
- Reviews cases related to the quality of care delivered to Florida Community Care enrollees.
- Review and discern Critical and Adverse Incidents.
- Identifies and develops opportunities for innovation to increase effectiveness and quality.
- Serves as a resource and consultant to other areas of the company,
- May be called upon to represent the company to external entities.
- Attends or chairs committees as required such as Credentialing, QIC, Health Service, and others as directed by the Chief Medical Officer.
- Evaluates authorization requests in timely support of nurse reviewers; requiring initial and concurrent, utilization review that represent prior authorizationand manages the denial process.
- Evaluates authorization requests in timely support of care manager service reviews requiring home and community-based services requests for personal care, homemaker, adult companion care, adult day care, etc. that represent service authorizations.
- Monitors appropriate care and services through continuum among home and community-based services, assisted living facilities, skilled nursing facilities, and custodial care in an institional setting to ensure quality, cost-efficiency and continuity of care in long-term care.
- Ensures that medical decisions are rendered by qualified medical personnel, not influenced by fiscal or administrative management considerations, and that the care provided meets the standards for acceptable medical care.
- Implements plan medical policies and procedures.
- Assists the Chief Medical Officer in updating plan policies and procedures.
- Provides implementation support for Quality Improvement activities.
- Stabilizes, improves and educates the Primary Care Physician and Specialty networks.
- Monitors practitioner and provider of service (vendors) of practice and care delivery patterns and recommends corrective actions if needed.
- Works with Provider Relations in contract negotiation.
- Fosters clinical practice guideline implementation and evidence-based medical practice.
- Utilizes IT and data analysts to produce tools to report, monitor and improve Utilization Management.
- Actively participates in regulatory, professional and community activities.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.
- Requires MD or DO from an accredited medical school
- Required active and unrestricted Florida License
- Board Certification or Eligibility in a primary care specialty preferred
- Board Certification in any of the areas of utilization management, quality assurance, post-acute care, long-term care, or managed care is preferred
- Master in Business Administration, Public Health, Healthcare Administration is preferred
- Proven experience with AAAHC or NCQA accreditation, HEDIS, CAHPS, Medicaid (Managed Medicaid Assistance, Long-term care), Medicaid Pharmacy Benefit and Preferred Drug List (PDL) management, and Medicare.
- Knowledgeable about managed healthcare systems, quality improvement, long-term care utilization management, risk management, risk adjustment, disease management, and evidence-based guidelines.
- Experience demonstrating strong management and communication skills, consensus building and collaborative ability, and financial acumen
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
KNOWLEDGE, SKILLS AND ABILITIES
- Knowledge and experience in long-term care is required
- Experience in Medicaid is required and Florida Medicaid is preferred
- Knowledge or experience in Medicare managed care is preferred
EDUCATION AND EXPERIENCE
- 5+ years clinical practice
- 2 years experience as a health plan Medical Director
- 2 years experience in post-acute and/or long-term care utilization and managment
- 2+ years HMO/Managed Care experience.