$183K – $258K – $183K – Assist the Vice President of Medical Affairs to direct and coordinate the medical affairs functions for the business unit. Oversee the denials and appeals department. May manage other medical directors. Assume VPMA responsibility in absence of VPMA. This is a non-clinical position in an office setting.
Provide medical leadership for all utilization management, pharmacy, case management, disease management, cost containment, and medical quality improvement activities. Perform medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services. Support the effective implementation of performance improvement initiatives for capitated providers.
Assist VPMA in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members. Provide medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.
Assist the VPMA in the functioning of the physician committees including committee structure, processes, and membership. Oversee the activities of physician advisors and other medical directors.
Utilize the services of medical and pharmacy consultants for reviewing complex cases and medical necessity appeals. Participate in provider network development and new market expansion as appropriate. Participate in provider profiling initiatives.
Assist in the development and implementation of physician education with respect to clinical issues and policies.
Identify utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components.
Identify clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice by profiling providers in order to improve the quality and cost of care. Interface with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality.
Review claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment.
Develop alliances with the provider community through the development and implementation of the medical management programs. As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues.
Represent the business unit at appropriate state committees and other ad hoc committees.
Oversee all aspects of the Appeals and Denials department including implementing budgetary, policy, and personnel decisions for the department.
Medical Doctor or Doctor of Osteopathy, board certified in a primary care specialty (Internal Medicine, Family Practice, OB/GYN, Pediatrics or Emergency Medicine).
Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is preferred.
Previous management experience including responsibilities for hiring, training, assigning work and managing performance of staff.
Previous experience within a managed care organization and with Medicaid programs is preferred.
Experience treating or managing care for a culturally diverse population preferred.
License/Certification: Board Certification through American Board Medical Specialties