This job was posted by https://idahoworks.gov : For more information,
please see: https://idahoworks.gov/jobs/2196797 Surgical Associate
Medical Director or Medical Director (DOE)
Remote in ID, OR, WA, UT
*Experience in a surgical specialty and/or coding experience is
required*
These roles will participate in utilization management, provide clinical
leadership and support to clinical teams to ensure our members receive
quality, cost effective care yielding optimal outcomes.
General Functions and Outcomes May Include:
- Provides clinical leadership for staff to ensure members receive
safe, effective and cost efficient services.
- Contributes to the development of various medical management
strategies and tactics to drive results and achieve key performance
metrics.
- Conducts peer clinical review for medical necessity on utilization
management authorization requests.
- Provides clinical input on case management reviews working closely
with the CM clinical staff.
- Responsible for discussing review determinations with providers who
request peer-to-peer conversations.
- Participates on multiple teams to provide clinical input on medical
policy reviews and development and may participate on committees
that develop programs impacting clinical interventions, utilization
management and case management.
- Analyzes and uses data to guide the development and implementation
of health care interventions that improve value to the member and
employer.
- Advises Health Care Services Leaders on related key performance
metrics and the effectiveness of various efforts, initiatives,
policies and procedures.
- Identifies and communicates new opportunities in utilization
management, provider contracting or other areas that would enhance
outcomes and the reputation of the organization.
- Provides clinical expertise and coordinates between internal
clinical programs and providers of care to improve the quality and
cost of care delivered to health plan members.
- Ensures ethical decision making in compliance with contractual
arrangements, regulations and legislation.
- Supports internal communication or training that ensures service is
provided to members and providers by a well-trained staff.
- Promotes provider understanding of utilization management and
quality improvement policies, procedures and standards.
- Provides guidance and oversight for clinical operational and
clinical decision-making aspects of the program.
- Has periodic consultation with practitioners in the field and
ensures that the organization has qualified clinicians accountable
for decisions affecting consumers.
- May manage staff including hiring, performance management,
development and retention.
- May participate in health plan credentialing operations and clinical
aspects of the credentialing program and provider services support.
Minimum Requirements
- Demonstrated competency working with hospitals, provider groups or
integrated delivery systems to effectively manage patient care to
improve outcomes.
- Strong communication and facilitation skills with internal staff and
external stakeholders, including the ability to resolve issues and
seek optimal outcomes.
- Proven ability to develop and maintain positive working
relationships with community and provider partners.
- Knowledge of the health insurance industry, state and federal
regulations, provider reimbursement methods and evolving accountable
care and payment models.
- General business acumen including understanding of market dynamics,
financial/budget management, data analysis and decision making.
- Strong orientation to the application of data in managing health and
quality.
- Proven ability to develop creative strategies to accomplish goals
and objectives, plan and execute complex projects and programs and
drive results across internal teams and/or external partners.
- Demonstrated ability to effectively lead and engage in a
constructive manner with others.
N
o
rmally to be proficient in the competencies listed above
Associate Medical Director would have a MD or DO degree, at least 3
years clinical experience, or equivalent combination of education and
experience.
Medical Director would have a MD or DO degree, at least 5 years clinical
experience, plus at least 2 years medical utilization management and/or
case management experience (prefer health insurance experience and
additional MHA or MBA training), or an equivalent combination of
education and experience.
Required Licenses, Certifications, Registration, Etc.
Licensed Physician with an MD or DO degree. Active, unrestricted license
to practice medicine in one or more states or territories of the United
States, With one of these licenses in our four-state area (OR, WA, ID,
UT). Applicant must also live in four state area. Board Certification
required. Qualification by training and experience to render clinical
opinions about medical conditions, procedures