Medical Director

Duties And Responsibilities

• Work closely with the CMO to establish a clinical strategy to meet the medical management PMPM performance targets while promoting quality healthcare for the plan’s members.
• Oversee the Associate Medical Directors and Medical Consultants to ensure that all departments of the plan have access to physician input. This includes providing clinical expertise during established rounds, and on an as needed basis for clinical programs including case management, disease management or any other clinically based programs.
• Provide oversight of the scheduling, payroll, and budget for the Medical Director Department.
• Ensure that clinical expertise is maintained in the Medical Review process by establishing processes and target expectations for inpatient and outpatient utilization review. These activities include...
• Serve as Chair/ oversight of the Pharmacy and Therapeutics committee.
• Serve as Chair of the Utilization Management Committee. This includes ultimate oversight of Clinical Medical Policies.
• Provide oversight to the AMD running the Clinical Affairs Committee.
• Provide or facilitate clinical expertise for the following functions:
• Credentialing activities, including approval and re-approval processes.
• Fraud, waste and abuse activities.
• Behavioral Health management with oversight of the BH medical director.
• Care Management
• Participate in the NCQA Readiness, D-SNP Quality Committee, & Medicaid and Commercial Quality Committee
• Provide management oversight of the Credentialing Team and Health @ Home Team.
• Engage in on-going performance management of staff including coaching, mentoring, development, Training and succession planning to include hiring and termination decisions.
• In coordination with the CMO, represent Neighborhood in internal and external meetings and forums withProviders, vendors, and regulators. This includes the management of the interactions with the regulatory bodies (OHIC/EOHHS/CMS) as well as statewide stakeholders such as CTC, PCMH Kids.
• Perform other duties as assigned

Qualifications

• Active, unrestricted Physician license in the State of Rhode Island; with no restrictions in any state
• Board eligible in a primary care or other relevant specialty
• Three (3)+ years clinical practice experience
• Two (2)+ years of Health Plan experience
• Excellent analytical and communication skills

Preferred

• Ongoing part-time clinical practice preferable
• Two (2) + years Quality Management experience
• Strong knowledge of Managed Care, Medicaid, and Medicare line of business

Neighborhood Health Plan of Rhode Island is an equal opportunity employer.