JOB SUMMARY:Oversees all medical care for COMPANY products and services. Oversees the health care needs of the membership. Services as the principal medical manager and policy advisor to the company and health plan CEO or COO. Is accountable for and provides professional leadership and direction to the utilization/cost management and clinical quality management functions. Works collaboratively with other plan functions that interface with medical management such as provider relations, member services, benefits and claims management, etc. Assists in short and long range program planning, total quality management (quality improvement) and external relationships. Works with Corporate Health and Medical Affairs for support, assistance and direction in overall medical management effectiveness. Reports all issues of clinical quality management to the health plan CEO,COO, the Board and the Chief Medical Officer (CMO) of Corporation. Collaborates with the CMO and other health plan medical directors on national medical policies and carries out national medical policies at the health plan in collaboration with the health plan CEO or COO
PRIMARY RESPONSIBILITIES: 1.Responsible and accountable to the CEO and COO and the Board for managing health plan medical costs and assuring appropriate health care delivery for health plans, products and services. Reports organizationally to the CEO or COO of the Health Plan; has a dotted line relationship to the Chief Medical Officer. 2.Plans, organizes, and directs the professional medical services program, consisting of all primary and specialty services for in-patient, out-patient, preventive and wellness programs. 3.Designs and implements health plan medical policies, goals and objectives. 4.Provides professional leadership and direction to the functions within the Medical Management Department (Utilization/Cost Management and Clinical Quality Management) 5.Responsible for and assists with the development of budgets, staffing plans and medical loss ratio projections, assuring the adequate allocation of resources to the medical management functions. 6.Responsible and accountable for the Utilization/Cost Management Program and Clinical Quality Improvement Program. Performs annual evaluation of these programs and reports findings to the plan CEO, the Quality Management Committee and to Corporate Medical Affairs. Develops and annual Utilization/Cost Management and Clinical Quality Improvement work plan based on the annual program evaluation and feedback from peer review committees, QA committee, Corporate Medical Affairs, the CEO and the Board. 7.Assists the CEO with activities to promote positive community relations. 8.Assures plan conformance with legal and regulatory requirements. Interacts with regulatory agencies. 9.Creates and maintains a system that gives feedback to providers individually and collectively regarding managed care effectiveness of individual providers and networks. 10.Designs and implements corrective action plans to address issues and improve plan and network managed care performance. 11.Collaborates with Corporate Medical Affairs and the health plan CEO in creating and maintaining programs that incentivize providers to achieve selected utilization/cost and quality outcomes. 12.Participates in policy review, performs analysis and makes recommendations. 13.Participates in the retrospective review and analysis of Plan performance from summary data of paid claims, encounters, authorization logs, compliant and grievance logs and other sources. 14.Achieves and maintains benchmarked utilization and cost management (UM) goals and clinical quality improvement (QI) objectives. 15.Provides periodic written and verbal reports and updates as required in the Quality Management Program description, the Annual Work Plan and A Community Care policy and procedures to various plan committees, the health plan CEO and Corporate Medical Affairs. 16.Supports URAC and NCQA qualification activities. Prepares for site visits and responds to accrediting and regulatory agency feedback. 17.Supports pre-admission review, utilization management, and concurrent and retrospective review process. 18.Participates in risk management, claim adjudication, pharmacy utilization management, catastrophic case review, outreach programs, HEDIS reporting, site visit review coordination, triage, nutrition service review, provider orientation, credentialing, profiling, etc. 19.Conducts quality improvement and outcomes studies as directed by the state Departments of Health, the Quality Management Committee, Medical Advisory Committee, Peer Review Committee and management. Reports findings. 20.Participates in the grievance process, insuring a fair outcome for all members. 21.Monitors member and provider satisfaction survey results and implements changes as needed to increase satisfaction and assure that satisfactory relationships are maintained between network and plan participants. 22.Establishes and reviews standards for professional and technical staffing ratios for vendors and providers to ensure their ability to deliver medical services to plan members. 23.Participates actively in provider recruitment. 24.Assists the contracting process of providers, hospitals, ancillary providers, and emergency and other support services, and evaluates the medical aspects of provider contracts. 25.Chairs (or delegates leadership of) the Medical Advisory Committees of the health plan which include (but are not limited to) the Peer Review Subcommittee and the Credentialing Subcommittee of the Quality Management Committee. 26.Participates in key marketing activities and presentations. 27.Promotes wellness and ensures programs of prevention, education and outreach to members and providers consistent with AMERICAIDís mission, vision and values. 28.Maintains up-to-date knowledge of new information and technologies in medicine and their application to the AMERICAID health plan. 29.Performs and oversees in-service staff training and education of professional staff. 30.Represents COMPANY at medical group meetings, conferences, etc. 31.Participates in the development of strategic planning for existing and expanding business. Recommends changes in program content in concurrence with changing markets and technologies. 32.Participates in key marketing activities and presentations, as necessary, to assist the marketing effort. 33.Ensures that the Utilization Management Program is available on a 24 hour basis to respond to authorization requests for emergency and urgent services and is available, at a minimum, during normal working hours for inquiries and authorization requests for non-urgent health care services. 34.The medical director must ensure that a covered person enrolled in the Plan is permitted to: a.choose or change a primary care physician from among participating providers in the provider network; and b.when appropriate, choose a specialist from among participating network providers following an authorized referral, if required by the carrier, and subject to the ability of the specialist to accept new patients. 35.Other duties as requested or assigned.
Education and Experience: ∑Masters in Public Health, MBA or MA preferred. ∑Continuing education to remain current in medical and management areas. ∑Five years of clinical experience in the practice of medicine, two of which have been in medical and/or health administration. ∑Three to five years of management and /or clinical experience in a managed care environment. ∑Any equivalent combination of education and experience.
Certification and Licensure: ∑Certified in a recognized medical specialty as recognized by the American Board of Medical Specialist (ABMS). ∑Must be licensed in the Plan state as a Doctor of Medicine or Doctor of Osteopathy. ∑Active license to practice medicine issued by the State Board of Licensure or the State Board of Osteopathic Examiners. ∑Certification by the American Board of Quality Assurance and Utilization Review Physicians or the American Board of Medical Management desired but not required.
Knowledge and Skills: ∑Management skills to meet the organizational goals. ∑Must possess excellent communications skills to interface with providers, staff, and management. ∑Knowledge of medical, quality improvement and UM practices in a managed care environment. ∑Knowledge of regulatory and accreditation agencies and requirements. ∑Able to manage multiple priorities and deadlines in an expedient and decisive manner. ∑Able to manage difficult peer situations arising from medical care review. ∑Appreciation of cultural diversity and sensitivity towards target population.