Medical Director
Carewise Health 8 reviews - Kentucky

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As a Medical Director within the Health Management Solutions Strategic Business Unit you will leverage your clinical practice experience to provide medical guidance and leadership with regards to the delivery of telephonic UM/CM, DSM, and Triage services to our large employer clients. You will work closely with our clinical nurse units to provide medical oversight and case review, improving care coordination and cost effective care delivery. You will also provide oversight to a Clinical Information team responsible for providing high quality decision support tools for on-line counseling and patient education.

Position Responsibilities:
  • Active in the overall medical management program and outcomes related to length of stay, patient days, admission data and other utilization data
  • Participates in the development and implementation all medical policy and procedures including all clinical protocols, surveys and other clinical tools and maintains them
  • Reviews procedures requiring prior authorization to determine medical necessity and coverage under a members benefit plan
  • Reviews requests for elective admissions to determine medical appropriateness of the inpatient setting
  • Conducts concurrent review of inpatient hospital stays, making medical necessity decisions
  • Works closely with concurrent review nurses and discharge planners to improve coordination of care and transition of hospitalized members to lower levels of care
  • Provides peer-to-peer communication involving cases under review to promote cost effective provision of medical services
  • Reviews cases enrolled in complex case management (CCM) to improve care coordination and cost effective care delivery; interacts with managing physicians as required to improve care coordination
  • Provide oversight and direction to the clinical information team and function
  • Reviews cases enrolled in disease state management with nurse advocates to promote adherence to evidence based guidelines; and communicates peer-to-peer to improve guideline compliance as required by individual circumstances
  • Actively participates in ongoing committees.
  • Participates in the continuing education process for both the physician and nursing clinical staff
  • Supports client meetings as assigned, including reviewing and providing input into written client presentations
  • Participates in SHPS quality improvement process, as a member of the quality improvement committee, by supporting accreditation standards and site visits and making recommendations to improve both clinical and service quality
  • Participates in the periodic URAC and other accreditation processes as required
  • Adheres to regulatory and accreditation requirements, including required turn-around time for decisions requiring a physician reviewer
  • Other duties as assigned
Experience/Education:
  • Unrestricted medical license in home state (KY)
  • 3+ years of experience in a managed care environment, with strong background in utilization management
  • 5+ years of clinical practice experience
Board certification in an ABMS recognized specialty

  • Team player with team building skills
  • Ability to multi-task and balance multiple priorities
  • Good written and oral communication skills
  • Metric driven with good data analysis skills
  • Ability to form relationships with providers and influence provider behavior
  • Strong familiarity with utilization management criteria (e.g. Milliman)

About this company
8 reviews