POSITION SUMMARY/RESPONSIBILITIES
Reporting to the Chief Medical Officer, this position provides clinical leadership and oversight for utilization management activities across multiple product lines. while supporting the multidisciplinary member centric approach to care management. This role ensures all determinations are accurate, timely, and compliant with regulatory standards, contractual requirements, and health plan policies while promoting a member-centric approach aligned with Community First Health Plans, Inc., (Community First) mission, vision, and Triple Aim Plus objectives, improving population health outcomes, enhancing member experience, containing costs, and improving access to care. The Medical Director collaborates across departments to drive quality, efficiency, and integrated care delivery.
EDUCATION/EXPERIENCE
A medical degree as Doctor of Medicine (MD) or Osteopathy (DO) and an active and unrestricted Texas Medical License, free of sanctions from Medicaid or Medicare is required. A minimum of five years of direct clinical patient care experience post residency is required. Clinical experiences in inpatient, LTAC, and Nursing Facility setting are preferred. A minimum of two years' experience in population health management is preferred. Prior leadership position in managed care, with a comprehensive understanding of utilization review and quality management procedures, including Medicaid, Medicare, Commercial and Marketplace programs, is highly desirable. A primary care specialty is also preferred.
LICENSURE/CERTIFICATION
Current unrestricted license as Doctor of Medicine or Osteopathy for Texas is required. Board certification is required.
