Medical Director - Medicaid Managed Care
Managed Care & Health Insurance
Position Purpose: Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit.
- Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities. Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services. Supports effective implementation of performance improvement initiatives for capitated providers.
- Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members. Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.
- Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership. Oversees the activities of physician advisors. Utilizes the services of medical and pharmacy consultants for reviewing complex cases and medical necessity appeals.
- Participates in provider network development and new market expansion as appropriate. Assists in the development and implementation of physician education with respect to clinical issues and policies.
- Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components. Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care. Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality. Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment.
- Medical Doctor or Doctor of Osteopathy, board certified preferable in a primary care specialty (Internal Medicine, Family Practice, Pediatrics or Emergency Medicine).
- The candidate must be an actively practicing physician.
- Previous experience within a managed care organization is preferred.
- Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is preferred.
- Experience treating or managing care for a culturally diverse population preferred.
License/Certifications: Board Certification through American Board Medical Specialties. Current state medical license without restrictions.
More information about the job
Is Relocation Available?
Is there a bonus structure?
20% or higher
Are you open to sponsorship?
This position is:
Is there a possibility to work remote?
Is there equity?
Are there flexible work hours?
Does this position have direct reports?
What are the 3-4 non-negotiable requirements on this position?
* Medical Doctor or Doctor of Osteopathy, board certified preferable in a primary care specialty (Internal Medicine, Family Practice, Pediatrics or Emergency Medicine).
* The candidate must be an actively practicing physician .
* Previous experience within a managed care organization
* Board Certification through American Board Medical Specialties. Current state medical license without restrictions.
Does this describe the next step in your career? If so, now is the time!