Associate Medical Director

Job Responsibilities

• Monitor availability, appropriateness, and necessity of care rendered by participating providers and by out-of-plan providers
• Participate in oversight and clinical decision making of the UM program
• Contribute to the development of quality care guidelines, internal peer review procedures, and the evaluation of medical care evaluation studies
• Provide medical consultation as requested
• Develop and implement new benefit packages and interpret covered benefits in NHP contracts
• Determine if services to members/enrollees meet medical criteria
• Promote positive relationships between NHP and the medical community
• Serve as liaison between NHP and providers regarding medical policy and administration
• Respond to physicians and other provider inquiries and complaints within established guidelines
• Aid in the training of NHP staff on matters relating to medical guidelines
• Oversee the monitoring and evaluation of Medicare Special Needs Plan Model of Care effectiveness
• Perform second level review of provider appeals and disputes
• Serve on committees as coordinated with the CMO
• Aid in strategic planning targeted towards plan growth initiatives

Job Requirements

• Doctor of Medicine (MD or DO), licensed in the state of Wisconsin without restriction
• Member in good standing of the local medical community
• Active practitioner of medicine in the NHP service areas
• Sufficient medical experience and other experience, including knowledge of the Medicare program, to review organization determinations involving medical necessity
• Board certified in an ABMS medical specialty required