The Medical Director (Director) provides medical decision making to utilization management (UM) and care management (CM) processes to ensure that the healthcare and services provided to Plan members are medically necessary, appropriate, and meet medical practice standards. This position is accountable for managing related health plan medical costs and assuring appropriate health care delivery for DHP plans, products and services. The Director provides clinical leadership to the UM and CM areas. Works collaboratively with departments that interface with QCM, and with Division leadership to promote and achieve departmental and organizational goals. relates to Medical Management are maintained.
Essential Job Duties:
1. Responsible for timely evaluation, documentation and decisions on referrals from the UM department for medical necessity, out of plan or network referral criteria, or appropriateness. Provides medical decision making and utilization review for pharmacy and drugs. Has authority and accountability for UM decisions that impact approval or denial of payment for services. Communicates with providers on cases for medical necessity or appropriateness criteria, including review and research of denial appeals through peer-to-peer process.
2. Promotes timely and effective communication and adequate information flow. Communicates and educates staff and providers on care management programs, medical policies and procedures. Functions as liaison between the Health Plan and Dean Health System.
3. Provides clinical leadership and program participation in Care Management and Pharmacy areas; provides medical decision making and utilization management for pharmacy and drugs.
4. Assists in medical management program planning, total quality management and external relationships.
5. Collaborates with the leadership team and other health plan medical directors and carries out national medical policies at the health plan in collaboration with our internal and external customers.
6. Provides clinical expertise to other Plan functions or departments such as claims and coding.
7. Provides leadership for the development of Dean Health Plan medical policies and procedures. Designs and implements health plan medical policies, goals and objectives. Performs current and new technology assessments for coverage determination and medical policy updates. Maintains up-to-date knowledge of new information and technologies in medicine and their application to the health plan through evidence-based methodology. Makes recommendations to the Senior Medical Director on company direction in these areas.
8. Works with business intelligence to interpret data and trends such as physician and facility profiles. Reviews reports on cost and utilization management to identify areas for improvement. Reviews clinical and claims data, analyzes results and provides written reports.
9. Accountable for implementing the Utilization/Cost Management Program and Clinical Quality Improvement Program. Assists the Chief Medical Officer and Senior Medical Director with continuous Quality Improvement activities that help achieve Plan goals and NCQA accreditation.
10. Responsible for ensuring that adherence to NCQA standards as it relates to Medical Management are maintained Partners with Director of Care Management and Director of Pharmacy to ensure compliance with regulatory and accreditation requirements.
11. Evaluates quality and utilization related issues, and is responsible for quality review referrals. Accountable for reporting all issues of clinical quality management to health plan senior medical leadership.
12. Supports DHP Grievance and Appeals department through research, medical record reviews and analysis of reports from external reviewers.
13. Serves on Company committees and performs additional responsibilities as deemed necessary by Medical Affairs leadership.
1. Doctorate Degree in Medicine, active Board Certification and an unrestricted license to practice medicine in WI.
2. Minimum 5 years of direct clinical care experience, including facility with electronic medical records.
3. Minimum 2 years managed care experience or equivalent, with knowledge of medical economics of health plans, payment systems and coding fundamentals.
4. Excellent interpersonal and communication skills, with an ability to apply analytical thinking and problem solve.
1. Leadership experience and participation in process improvement initiatives.