Associate Medical Director
Neighborhood Health Plan of Rhode Island - Providence, RI

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Overview

The role of the Associate Medical Director is to provide clinical support to the Medical Management Department,
whose goal is to promote quality, access and member satisfaction in health care services.

Qualifications

Required

  • Physician with unrestricted license, willingness to obtain Rhode Island medical license if not currently licensed
in RI, no restrictions in any state
  • Board certified in a primary care or other relevant specialty
  • Excellent analytical and communication skills
Preferred

  • Ongoing part-time clinical practice
  • Previous managed care experience
  • Clinical experience with geriatric populations
Duties and Responsibilities

Responsibilities include, but are not limited to the following:

  • Participate in program development for existing and new lines of business.
  • Provide clinical expertise to the Medical Review process by
o performing review of medical and pharmacy requests for non-benefit or restricted benefit services
o engaging prescribers in discussions of medical necessity
o notifying members and prescribers of decisions
o guiding development of Clinical Benefit Guidelines
o participating as a member of the MCAP Advisory Council
o meeting all regulatory expectations of review processes
  • Serve as clinical resource to Medical Management for
o Neighborhood Clinical Guidelines development and maintenance
o clinical programs ( eg Asthma, Diabetes, Bright Start)
o research and consultation as requested by nurse case managers
  • Provide clinical expertise to the Quality Assurance process by performing review and recommendation for member
and provider complaints, and participate as a member of the Quality Assurance Committee in decision for actionable
follow-up to complaints.
  • Lead the new technology review process by performing reviews of new technologies or new applications of existing
technologies, by chairing the Medical Technology Review Committee, and by leading decision-making for addition of
new technologies to the list of benefits for Neighborhood members
  • Serve as clinical resource to Claims Department for review and processing of administrative denials
  • Assist in preparation for regulatory and accreditation reviews
  • Serve as member of Quality Improvement and Pharmacy and Therapeutics Committees
  • At the direction of the Medical Director, perform review of credentials for participating provider approval and
re-approval processes
  • At the direction of the Medical Director, represent Neighborhood in meetings or other forums with practitioners,
regulators, purchasers, etc.
  • Comply with Neighborhood policies and procedures on Confidentiality
  • Perform other duties as assigned by the Medical Director
Neighborhood is an EOE M/F/D/V and an E-Verify Employer.

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The overall health of the people of Rhode Island is overseen by the Rhode Island Department of Health, which is overseen by a...