Position Purpose: Direct and coordinate the medical management, quality improvement, and pharmacy functions for the assigned business unit based on, and in support of the strategic plan, establishing the strategic vision and policies and procedures. Responsible for all state required initiatives related to medical affairs.
Oversees utilization management, cost containment, and medical quality improvement activities. Manages 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.
Recruits, coordinates and oversees activities of assistant medical directors and physician advisors. Recruits and utilizes the services of medical and pharmacy consultants for reviewing complex cases and medical necessity appeals.
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 the in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care. Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment.
Responsible for business unit physician committees including committee structure, processes, and membership.
Education/Experience: Requires a Medical Doctor or Doctor of Osteopathy, board certified required in a primary care specialty (Internal Medicine, Family Practice, Pediatrics or Emergency Medicine). Previous experience as Medical Director is preferred. Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is desired. Experience treating or managing care for a culturally diverse population preferred.
License/Certificates: Board Certification through American Board Medical Specialties. Current state medical license without restrictions. Current state driver’s license