Medical Director

About the role

At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you’ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion, and a sense of belonging at every level. Here, you’ll be encouraged to bring your authentic self to work with all your unique abilities.

Primary Responsibilities

• Creates and updates medical policies and procedures in conjunction with associate medical directors and other clinical staff and assures consistency and compliance with generally accepted medical standards and guidelines.
• Provides clinical support for all areas of Clinical Services.
• Review medical files and make coverage and medical necessity determinations using good judgement combined with 3rd party and proprietary medical guidelines.
• Identify, critique, and utilize criteria and resources such as national, state, and professional association guidelines and peer reviewed literature to support sound and objective decision making and rationales in reviews.
• Advises team nurses on appropriateness of care and services through the care continuum including hospitals, skilled nursing facilities, and home care to ensure quality, cost-efficiency and continuity of care; Informs the UR Nurse of certification decisions within appropriate time frames as guided by URAC, ERISA or state regulations.
• Serves as medical expert for care management and population health; reviews and evaluates cases with review nurses; ensures medical care provided meets the standards for acceptable medical care.
• Reviews and resolves retro reviews, appeals and grievances related to medical quality of care and actively participates in the functioning of the plan’s grievance and appeals processes.
• Along with the nurse supervisor and manager identify opportunities for improvement and collaborate to enhance team performance.
• Makes appropriate outreach to community and academic based treating providers wanting to discuss cases.
• Interacts telephonically and personally with employees/departments in order to maintain effective communication and support for and among departments, as well as a positive work atmosphere.
• Opportunity to interact with sales and account management supporting client needs.
• Collaborates with other departments i.e. Member Services, Provider Services, Claims and Contracting, to improve performance.
• Attends departmental committees as assigned.
• Performs other duties as required by the business.
• Maintain proper credentialing and state licenses and any special certifications or requirements necessary to perform the job.
• Board certified with an excellent understanding of the utilization and case management process.
• 3 years’ experience working in a managed care environment supporting utilization management and case review with medical necessity determinations.
• Case management and / or Population Health Management desirable.
• 3 + years of prior clinical practice in either an office or hospital-based setting with boards from any of a wide range of Internal Medicine specialties so long as you are self-motivated to stay up to date on a broad range of medical services using resources such as mcg guidelines, specialty society guidelines, Up-To-Date and other resources to analyze existing cases.
• Specialty training in addition to a first board certification highly desirable.
• Current, unrestricted clinical license(s).
• Board certification by American Board of Medical specialties or American Board of Osteopathic Specialties, in Internal Medicine or Pediatrics or a subspecialty of Internal Medicine or Pediatrics, is required for MD or DO reviewer.
• Ability to communicate clearly and concisely, both verbally and in writing.
• Knowledge of evidence-based medical guidelines (nationally recognized standards of health care), utilization management, quality improvement and other medical management functions.
• Good interpersonal and communication skills to support the team approach.
• Ability to work proficiently on a computer and knowledge of basic programs.

Qualifications

• Board certified with an excellent understanding of the utilization and case management process.
• 3 years’ experience working in a managed care environment supporting utilization management and case review with medical necessity determinations.
• Case management and / or Population Health Management desirable.
• 3 + years of prior clinical practice in either an office or hospital-based setting with boards from any of a wide range of Internal Medicine specialties so long as you are self-motivated to stay up to date on a broad range of medical services using resources such as mcg guidelines, specialty society guidelines, Up-To-Date and other resources to analyze existing cases.
• Specialty training in addition to a first board certification highly desirable.
• Current, unrestricted clinical license(s).
• Board certification by American Board of Medical specialties or American Board of Osteopathic Specialties, in Internal Medicine or Pediatrics or a subspecialty of Internal Medicine or Pediatrics, is required for MD or DO reviewer.
• Ability to communicate clearly and concisely, both verbally and in writing.
• Knowledge of evidence-based medical guidelines (nationally recognized standards of health care), utilization management, quality improvement and other medical management functions.
• Good interpersonal and communication skills to support the team approach.
• Ability to work proficiently on a computer and knowledge of basic programs.

Skills

• Excellent understanding of the utilization and case management process.
• Experience in a managed care environment supporting utilization management and case review with medical necessity determinations.
• Case management and / or Population Health Management.
• Specialty training in addition to a first board certification.
• Ability to communicate clearly and concisely, both verbally and in writing.
• Knowledge of evidence-based medical guidelines (nationally recognized standards of health care), utilization management, quality improvement and other medical management functions.
• Good interpersonal and communication skills to support the team approach.
• Ability to work proficiently on a computer and knowledge of basic programs.

Benefits

Annual Salary Range: $200,000-$235,000 - bonus eligible

Pay

$200,000 - $235,000 annually

Schedule

Full-time

Equal Opportunity Employer

We are an Equal Opportunity Employer