Assist the President and CEO to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit. This includes, but is not limited to, concurrent reviews, case management, and medical/behavioral health shared cases. Oversee the improvement of clinical outcomes and quality improvement, while improving the utilization of health care resources within the Cenpatico Corporate goals and objectives. The Medical Director will also interact with State and regulatory Stakeholders as needed.
Requires an unrestricted licensed Medical Doctor or Doctor of Osteopathy, board certification in Psychiatry. Previous experience within a managed care organization is preferred. Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is preferred. Familiarity with medical information systems, medical terminology, National Committee for Quality Assurance (NCQA) and URAC accreditation processes and standards.
• Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities. Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services. Supports effective implementation of performance improvement initiatives for capitated providers.
• Assists in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members. Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.
• Assists in the functioning of the physician committees including committee structure, processes, and membership. Oversees the activities of physician advisors. Utilizes the services of medical and pharmacy consultants for reviewing complex cases and medical necessity appeals. Participates in provider network development and new market expansion as appropriate. Assists in the development and implementation of physician education with respect to clinical issues and policies.
• Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components. Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care. Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality. Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment.
• Develops alliances with the provider community through the development and implementation of the medical management programs. As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues. Represents the business unit at appropriate state committees and other ad hoc committees
License/Certifications: Board certification by the American Board of Psychiatry and Neurology. Current state medical license without restrictions.
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