Medical Director

Position Purpose

Aid the Chief Medical Director in directing and coordinating medical management, quality improvement, and credentialing functions for the business unit. Provide medical leadership in utilization management, cost containment, and medical quality improvement activities.

Qualifications

• MD or DO without restrictions
• Licensed in one of the following states: MO, IL, KS, IA, NE, MI, WI, IN, OH, PA

Position Purpose

Support the Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members.

Responsibilities

• Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes.
• Collaborate effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals.
• Represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues.
• Participate in provider network development and new market expansion as appropriate.
• Develop alliances with the provider community through the development and implementation of the medical management programs.
• Interface with physicians and other providers to facilitate implementation of recommendations to providers that would improve utilization and health care quality.
• Review claims involving complex, controversial, or unusual or new services to determine medical necessity and appropriate payment.
• Identify utilization review studies and evaluate adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components.
• Identify clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care.
• Assist in the development and implementation of physician education with respect to clinical issues and policies.

Requirements

• Current state license as a MD or DO without restrictions, limitations, or sanctions from government programs.
• Board certification in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Association’s Department of Certifying Board Services (required for Psychiatry).
• Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is advantageous.
• Experience treating or managing care for a culturally diverse population preferred.

Benefits

Competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives.

Pay

$225,700.00 - $428,900.00 per year

Schedule

May be required to work weekends and holidays in support of business operations, as needed.