UnitedHealth Military & Veterans Services is part of the family of companies that make UnitedHealth Group one of the leaders across the US health care system.
We serve those who serve our nation, providing quality health care services to millions of military beneficiaries across the West Region
Our commitment to helping people live healthier lives, and to continue the honor, satisfaction, and quality of the TRICARE military health benefit program is greater than ever. Our efforts complement the Military Health System to demonstrate the best blend of public and private health care solutions.
It's not just business as usual. It is one of our proudest endeavors.
The Medical Director works actively to implement and administer medical policies, disease and medical case management programs, utilization management programs, integrate physician services, quality assurance, appeals and grievances, and regulatory compliance programs with medical service and delivery systems to ensure the best possible quality health care for TRICARE beneficiaries. Accountability for ensuring that initiatives focus on affordability, clinical excellence, TRICARE medical management program requirements and are implemented and successfully managed to achieve performance expectations. This position requires working closely with utilization management on such tasks as concurrent review and prior authorization review. The MD advises leadership on improvement opportunities regarding medical expense programs and clinical programs (CM, DM) that impact medical expense. The Medical Director for UMVS also provides leadership to clinical staff through case consultation and case review. Provides feedback on clinical performance to senior leaders with plans for clinical performance improvement. The impact of work is at the operational level for TRICARE. The Medical Director is accountable to manage resource allocation as is applicable to medical management practices under his or her scope of responsibility.
SUMMARY OF JOB RESPONSIBLITIES:
The Medical Director is responsible for clinical leadership within TRICARE and reports to the Chief Medical Officer and VP Medical Management Services.
OUTLINE OF ESSENTIAL JOB RESPONSIBILITIES/FUNCTIONS TO INCLUDE BUT NOT LIMITED TO:
1. Develops, coordinates and participates in medical management program design, development, implementation, oversight and monitoring as a medical leader within UMVS/TRICARE team:
Establishes and oversees standards of practice for TRICARE. Assures adherence to UHG and MHS/DoD clinical practice guidelines.
Working collaboratively with the Medical management senior leader in the development and implementation of medical expense management initiatives and medical management program development.
Oversees evaluation and management of medical practices within the requirements of a Multi-Function Peer Review Organization.
Works with the VP, Medical Management Services to ensure adherence to medical management performance standards including quality, utilization and program integrity.
Assigns, directs, and reviews the work of other medical staff, as assigned.
Plans and facilitates training and development of clinical staff to improve performance.
Provides for and recommends clinical program enhancements and quality improvements that adhere to the TRICARE requirements and reflect emerging clinical solutions and best evidences based practices.
Supports, communicates and facilitates TRICARE wide clinical programs and policies.
Provides clinical education to clinical staff to ensure TRICARE medical management program success
Analyzes population-based reports to refine management activities, investigate and define variation, and ensure conformance to expected standards and targets.
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.
Ensures compliance with policies, procedures, bylaws, regulatory requirements, and best practice guidelines.
Participates in the production of setting performance standards for clinical staff that aligns with program standards and the TRICARE contract. Monitors, assesses, reviews and evaluates clinical employee performance based on the established standards.
Works with the VP Medical Management Services to monitor, evaluate and manage the department/division budget; conduct trend analysis, and develop the approach and interventions to improve performance. .
2. Communicates effectively.
Provides clear and concise verbal and written instructions to ensure that instructions are understood.
Complete peer to peer communication, as required
Provide beneficiary case consultation for providers, MTF providers and staff, and UMVS clinical staff
Listens and asks for feedback from staff, physicians and customers.
Ensures that TRICARE network providers are kept up to date on changes that are occurring.
Addresses healthcare issues appropriately.
Uses the computer system in order to obtain beneficiary, clinical, research, and physician information.
3. Consults and coordinates with health care providers working in other departments and in other business units across UHG.
Â· Provides assistance to the health care providers by answering questions regarding
Â· Educates and interacts with network and group providers as well as clinical and case management staff regarding utilization practices and effective resource management.
Â· Works in coordination with the health care providers and case managers on high risk beneficiaries to put the most appropriate treatment plan in place for beneficiaries.
4. Works with all other staff in UMVS as a member of the team
Ensures that TRICARE staff understand the goals and objectives of the MHS for TRICARE beneficiaries and assists senior leadership to lead teams and adhere to the goals to comply with TRICARE requirements
Updates staff on a regular basis, as appropriate.
Participates in fulfilling the mission, vision, goals and objectives of the organization.
Oversees and participates on committees within TRICARE and UHG.
Ensures a safe work environment for staff who directly interact with beneficiaries
5. Participate in the development and implementation of the TRICARE clinical quality management program
Ensures consistent and continual monitoring of quality of care delivered.
Investigates selected cases reported as deviating from accepted standards and takes appropriate actions.
Participate in the HEDIS-like quality measure data extraction, reviews, and analysis. Provide recommendations for improvement of HEDIS-like measures as established within in TRICARE and other quality metrics set by UMVS.
Reviews completed charts on a regular basis as part of the Multi-function Peer Review Organization activities and for UMVS clinical staff monitoring and performance oversight.
Provides and receives consistent feedback on the quality of care being delivered.
Ensures URAC, NCQA and other regulatory standards are met as they apply to
UMVS and TRICARE.
Abides by policies, procedures and bylaws.
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