Medical Director

About the role

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. Prominence Health 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. 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 include Utilization Management, Care Management, Disease Management, Quality Improvement, Pharmacy Management, Risk Adjustment, and Community Provider Relations.

Responsibilities

• Provide leadership for the Utilization Management, Care Management, Disease Management, Quality Improvement, Pharmacy Management, Risk Adjustment, and Community Provider Relations departments.
• Participate with and lead other multi‑disciplinary or cross‑functional task‑oriented groups within PHP and, as appropriate, other internal and external units.
• Play a key role 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.
• Strategically develop and enhance 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.
• Provide the skills and experience necessary to work with the marketing and sales department to assist in new membership growth and key account retention.
• Work closely with Provider Relations, represent the organization at key community clinical functions, be visible at important regional and national meetings, and visit medical/hospital entities on a regular basis.

Requirements

• Hold an active, unrestricted, valid, and current license to practice medicine in Nevada, Texas, and/or Florida.
• Be board‑certified by a specialty board approved by the American Board of Medical Specialties or the Advisory Board of Osteopathic Specialists, or be a Doctor of Podiatric Medicine.
• Be qualified to render appeal determinations in addition to initial determinations and non‑certifications.
• Possess a license or certification in a health profession that permits the application of clinical judgement to render a utilization review determination.
• Be free of sanctions from MD Medicaid or Medicare; any allowed restriction must not affect the ability to fulfill reviewer responsibilities.

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 ABMS or AOA, or a Doctor of Podiatric Medicine preferred.
• Possess a current, valid, active, and unrestricted license or certification to practice medicine in a U.S. state or territory (unless expressly permitted by state/federal law).
• 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/URAC.

Skills

• Excellent computer skills.
• Strong internal relationship building skills required.
• Strong external relationship skills required with contracted providers.
• Excellent presentation, oral, and written communication skills required.
• Able 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 our Benefits Guest Website: benefits.uhsguest.com