Medical Director

Company Overview

Prominence Health is a value‑based care organization bridging the gap between affiliated health systems and independent providers, building trust and collaboration between the two. Prominence Health creates value for populations and providers to strengthen integrated partnership, advance market opportunities, and improve outcomes for patients and members. Founded in 1993, Prominence Health started as a health maintenance organization (HMO) and was acquired by a subsidiary of Universal Health Services, Inc. (UHS) in 2014. The company serves members, physicians, and health systems across Medicare, Medicare Advantage, Accountable Care Organizations, and commercial payer partnerships. Prominence Health is committed to transforming healthcare delivery by improving health outcomes while controlling costs and enhancing the patient experience. Learn more.

Universal Health Services (UHS) is one of the nation’s largest and most respected providers of hospital and healthcare services. UHS operates acute‑care hospitals, behavioral‑health facilities, outpatient sites, ambulatory‑care access points, an insurance offering, a physician network, and related services across the United States, Washington, D.C., Puerto Rico, and the United Kingdom. For more information, visit www.uhs.com.

Job Summary

Reporting to the Chief Medical Officer of Prominence Health Plan (PHP), the Medical Director will direct the development of goals and objectives and the activities related to their achievement for the Health Services Department of PHP, which includes Utilization Management, Care Management, Disease Management, Quality Improvement, Pharmacy Management, Risk Adjustment, and Community Provider Relations. The Medical Director will provide leadership for these departments and may be asked to participate with and lead other multi‑disciplinary or cross‑functional task‑oriented groups within PHP and, as appropriate, other internal and external units. Staff Medical Directors must hold an active, unrestricted, valid, and current license to practice medicine in Nevada, Texas, and/or Florida and be board‑certified by a specialty board approved by the American Board of Medical Specialties, the Advisory Board of Osteopathic Specialists, or be a Doctor of Podiatric Medicine. They are qualified to render appeal determinations in addition to initial determinations and non‑certifications. Physician reviewers have access to consult with initial clinical reviewers, other medical advisors, licensed doctors, or peer reviewers through several modes of contact. This individual is qualified, as determined by the medical director or clinical director, to render a clinical opinion or determination about the medical or behavioral health condition, procedures, and treatment under review and is knowledgeable of current evidence‑based clinical guidelines and novel treatments. The role will play a key part in the direction and execution of PHP’s success in Nevada, Texas, Florida, and other markets related to the delivery of medical services in a population‑management environment. The medical leader will be responsible for strategically developing and enhancing the existing Medical Management Service Department in the areas of medical policy and procedures, utilization management, peer‑to‑peer clinical review, pharmacy management, quality of care, quality of service, physician enhancement and development, case/disease management, and appropriate documentation and coding. Additionally, the leader will support marketing and sales efforts to assist in new membership growth and key account retention, work closely with Provider Relations, represent the organization at key community clinical functions, attend important regional and national meetings, and regularly visit medical/hospital entities.

Responsibilities

The Medical Director will direct the development of goals and objectives for the Health Services Department, lead Utilization Management, Care Management, Disease Management, Quality Improvement, Pharmacy Management, Risk Adjustment, and Community Provider Relations, and may lead additional multi‑disciplinary or cross‑functional task groups. The role includes rendering appeal and initial determinations, providing clinical opinions based on evidence‑based guidelines, managing medical policy and procedures, overseeing peer‑to‑peer clinical review, ensuring appropriate documentation and coding, supporting marketing and sales for membership growth, representing the organization at community and national events, and maintaining regular visits to medical and hospital entities across PHP markets.

Qualifications

• Doctorate degree in Medicine; a Master’s in health‑care administration or related field (MBA, MMM, MPH, or MHA) preferred.
• Board‑certified by a specialty board approved by the American Board of Medical Specialties, the Advisory Board of Osteopathic Specialists, or a Doctor of Podiatric Medicine (preferred).
• Current, valid, active, unrestricted license or certification to practice medicine in a U.S. state or territory, recognized in the relevant jurisdictions.
• Free of sanctions from MD Medicaid or Medicare.
• Qualified, as determined by the Chief Medical Officer or clinical director, to render clinical opinions about medical conditions, procedures, and treatments under review.
• License or certification that permits application of clinical judgment for utilization review determinations.
• For either a Doctor of Medicine or Doctor of Osteopathic Medicine; or the same license/certification as the ordering practitioner.
• Previous Associate Medical Director/Medical Director experience preferred.
• Minimum five years of clinical practice and post‑graduate experience in direct patient care.
• Familiarity with Managed Care Principles.
• Familiarity with HEDIS, CAHPS, STARS, HOS, NCQA, and URAC.

Skills

• Excellent computer skills.
• Strong internal relationship‑building skills.
• Strong external relationship skills with contracted providers.
• Excellent presentation, oral, and written communication skills.
• Ability to travel to all PHP markets and represent the Plan.

Benefits

• Loan Forgiveness Program
• Challenging and rewarding work environment
• Competitive compensation & generous paid time off
• Excellent medical, dental, vision, and prescription drug plans
• 401(k) with company match and discounted stock plan
• SoFi Student Loan Refinancing Program
• Career development opportunities within UHS and its 300+ subsidiaries
• More information available on the Benefits Guest Website: benefits.uhsguest.com