UHC Health Plan Medical Director- Nevada
The Medical Director provides leadership to the Health Plan's acute bed day management processes ensuring appropriate decisions are made that are in alignment with insurance product benefits and the level of care for members. Accountabilities include oversight of medical & clinical processes with a focus on implementing plans of care that meet accepted guidelines and protocols and ensure that optimal and appropriate medical & clinical services are provided. The Medical Director educates and interacts with network and group providers as well as clinical and case management staff regarding utilization practices and effective resource management. The Medical Director is accountable to manage resource allocation as is applicable to medical management practices under his or her scope of responsibility.
Provides guidance and direction to physicians and nurses regarding all aspects of medical care and multi-level transitions of care.
Reviews inpatient cases and is accountable for successful bed day management that meets established company goals.
Analyzes utilization data to identify trends and opportunities for process improvement related to medical treatment (inpatient and outpatient).
Supports overall regional and corporate goals to ensure continued growth and profitability of the Health Plan.
Participates in senior medical management strategy development and implementation to ensure that appropriate care and services provided to members meet best practice standards as well as regulatory compliance requirements.
Educates physicians and nurses in effective management of Health Plan benefits and medical services that meet the needs of the members and utilizes resources appropriately.
Establishes professional relationships with Health Plan and community leaders to assist with long term planning and support for problem resolution.
Participates and guides the review and updating of medical criteria protocols used by the Health Plan to ensure that the Health Plan is aligned with national standards and medical expectations.
Broad and comprehensive knowledge of medical management principles and insurance products for multiple and varied lines of business in a managed care environment. Strong knowledge of the community health care environment, the provider network and the managed care contracting processes. Good understanding of managed care systems, quality improvement and risk management.
Demonstrated excellent medical management and leadership skills required. Demonstrated excellent communication skills required. Good skills in making presentations and teaching required. Strong organizational and prioritization skills required.
MD or DO with an active, unrestricted license-in Nevada
Board Certified in an ABMS or AOBMS specialty
Minimum of 8 - 10 years of progressively responsible management experience preferably in a managed care setting.
Extensive record of performance, by meeting and exceeding operational goals in health care quality and cost management
Utilization Management experience required
Additional Assets Preferred :
Excellent interpersonal skills.
Ability to develop and maintain effective relationships with key external stakeholders including government representatives, industry staff and the wide spectrum provider community (medical and community based) that serves the Plan's members
Strong knowledge of managed care industry.
Excellent project management skills.
Data analysis and interpretation skills.
Ability to focus on key metrics.
Excellent presentation skills for both clinical and non clinical audiences.
Familiarity with current medical issues and practices.
Creative problem solving skills.
Visibility and involvement in medical and local communities.
Strong team player and team building skills.
Supervisory skills including clinical mentoring and coaching skills
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