Report to and partner with the VP of Integrated Services.
Monitor and guide the evidenced based delivery of health services, promote and maintain excellent relations with all customers (patience and physicians).
Ensure efficient operations of Integrated Services Department.
Provide physician leadership to staff and health care providers.
Provide innovative solutions that lead to high quality care, cost effectiveness and overall improved member health.
Serve as Chair or Co-Chair on medical advisory committees, including Utilization Management Committee, P&T Committee, Quality Management Committee and Medical Advisory Panel
Provide medical consultation on development and implementation of new and innovative benefit packages.
Determine the appropriate utilization of health care services in order to achieve high quality outcomes in the most cost effective manner.
Oversee the development of quality care guidelines, internal peer review procedures, evidence-based practice, integrative healthcare model and delivery system.
Serve in a professional and diplomatic manner as primary liaison between the Coordinated Care Organization (CCO) /Managed Care Organization (MCO) and providers regarding matters of medical policy and medical administration.
Oversee training of CCO/MCO staff on matters relating to medical management, guidelines, review criteria and benefit interpretations.
Monitor availability, appropriateness and necessity of care rendered by participating providers and out-of-network providers.
100% premiums paid for health, dental, and vision insurance
- Doctor of Medicine (MD) or Osteopathy (DO) (or the equivalent if a foreign medical graduate), licensed by the State of Oregon.
- Board eligibility or certification, preferably in a broad specialty area.
- 10+ years’ experience in healthcare administration in a clinical or insurance setting.
- Demonstrated passionate for providing integrated models of mental and physical health.
- Knowledge in the following areas:
- Prioritized List of Covered Services, Oregon Administrative Rule and Oregon Health Plan (OHP)/Department of Medical Assistance Program (DMAP) policy.
- Center for Medicare & Medicaid Services (CMS) guidelines and policies.
- Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) coding.
- CMS Risk Score methodology.
- Ability to maintain effective professional liaison with all levels of executive and medical staff that include professional and institutional providers of care.
- Broad knowledge of health care industry.
- Knowledge of current credentialing standards.
- Skills to effectively teach and train staff regarding current medical practices and internal medical policies.
- Ability to cultivate relationships with providers in order to support activities of Provider Relations department.
- Ability to provide effective clinical supervision to managers of Health Services and Pharmacy to enhance efficient and clinically appropriate operation of those departments.
- Effective provision of clinical expertise to all departments as needed.
401k plan with employer contribution
4 weeks PTO
Talence Group LLC - 8 months ago
The Talence Group has developed an innovative solution called "PerfectSelection". This method has been demonstrated over and over...