The Medical Director will provide clinical direction to health services and quality improvement functions for both Government and Commercial programs in the Idaho and Montana markets. Provide medical determinations and care coordination required for effective utilization and quality management of the health plan network. Accountable for management activities and clinical review activities for all product lines. Work in collaboration with the other Medical Directors to meet or exceed quality standards as established by all external agencies. Proactively engage all clinicians in the support of company strategies.
Review pre-authorizations, claims, referrals, and other cases involving pre- or post-service requests for coverage. May include medical, pharmacy and mental health service reviews.
Conduct other utilization review activities (e.g. lengths of stay, appropriateness of service, intensity of service, medical necessity, and experimental/investigational services) on a prospective, concurrent, or retrospective basis.
Provide expertise and medical interpretation with respect to claims adjudication, underwriting, contract language, disputes and appeals, policy drafts and care management issues.
Clinical review of Grievance and Appeals. Assist plan with preparation for external review. Represent plan with external agencies in appeal resolution.
Provide expertise and support to various strategic and operational initiatives.
Research new technologies, new medications, and other evolving healthcare products and services to help determine a standard of care and standard of coverage, as requested. Assist with drafting and revision of policies relating to such issues.
Participate in other clinical or administrative oversight, planning or management as designated from time to time.
Establish realistic guidelines, standards of care and standards of coverage to be applied as Health Services criteria.
Participate in the plan’s Quality Assurance Committee.
Assist in the application of appropriate care coordination and case management for catastrophic or complex/chronic care cases.
Working with the other Medical Directors or Chief Medical Officer, develop s integration programs that focus on consumer directed health care and patient self-management strategies.
Provide visibility and maintain positive practitioner relationships as a representative of PacificSource, in local and regional medical and behavioral health communities.
Coordinate business activities by maintaining collaborative partnerships with key departments. Actively participate as a key team member in manager/supervisor meetings.
Actively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy.
Implement continuous quality improvements within all aspects of essential responsibilities.
Meet department and company performance and attendance expectations.
Perform other duties as assigned.
Work Experience: Previous health plan experience preferred. Prior experience in application of clinical criteria and evidence based guidelines.
Education, Certificates, Licenses: Unrestricted license to practice medicine by the Idaho State Board of Medicine. Prefer board certification recognized by American Board of Medical Specialties (ABMS).
Knowledge: Comprehensive knowledge of business principles and techniques of administration, organization, and management to include an in-depth understanding of the key business issues that exist in the healthcare industry. These include, but are not limited to quality improvement including, Lean methodology, healthcare economics, personnel administration, financial and cost analysis, trends in the healthcare industry. Excellent understanding of all areas of medical conditions, treatment, and care. Excellent understanding of the insurance industry and risk factors and how they relate to the PacificSource organization. Remain current in the medical field. Basic computer skills preferred.
- Building Trust
- Building a Successful Team
- Aligning Performance for Success
- Customer Focus
- Continuous Improvement
- Facilitating Change
- Leveraging Diversity
- Driving for Results
- We are committed to doing the right thing.
- We are one team working toward a common goal.
- We are each responsible for customer service.
- We practice open communication at all levels of the company to foster individual, team and company growth.
- We actively participate in efforts to improve our many communities-internally and externally.
- We encourage creativity, innovation, and the pursuit of excellence.
Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 20% of the time.
Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.
Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.
PacificSource is an equal opportunity and affirmative action employer.
PacificSource Health Plans - 5 months ago
PacificSource Health Plans is anything but a typical health plan. We’re a growing, independent, not-for-profit organization with a 78-...