Benefits:

• 401(k)
• 401(k) matching
• Bonus based on performance
• Competitive salary
• Dental insurance
• Flexible schedule
• Paid time off
• Vision insurance
• Employee discounts
• Health insurance
• Parental leave
• Stock options plan
• Wellness resources
• Signing bonus

We are an HMO with a Medicare contract and is contracted with the Florida State Medicaid program for Dual Special Needs Plans.

Job Title: Medical Director (Onsite)
Work Location: Spring Hill, FL 34611
Position Type: Full-time Permanent
Compensation Details:
Base Salary: $300,00 to $330,000 (Negotiable)
Full Time Benefits: Full (Such as 21 days PTO, 7 days CME, $3,000.00 annual CME reimbursement, medical benefits paid for employee and dependents for the basic plan, etc.)

Summary: Responsible for administration of all clinical aspects of the Quality Management Program; works closely with the CEO and Quality Management Steering Committee (QMSC) in administering the entire program. Provides guidance for all programs managed by the Health Services Department, Case Management, Disease Management and Utilization Management and assures that decisions are based on medical necessity, appropriateness and quality. Oversees processes for appeals and grievances, credentialing, and pharmacy services, providing clinical and leadership support. Develops relationships, solicits input from, and assists with education and recruitment of participating providers. Also participates in Health Services activities related to Government programs, including but not limited to: CMS, accreditation, and State and Federal guidelines by performing the following duties either personally or through subordinate supervisors.

Essential Duties and Responsibilities include the following. Other duties may be assigned.
Provides guidance for all clinical operational aspects of the program and for oversight of all clinical decision-making aspects of the program.
Responsible and accountable to the Company for decisions affecting the clinical services that the Company providers to their members
Communicates and periodically consults with practitioners in the field to assist in the development and maintenance of a strong, quality network of providers.

Ensures the Company’s objectives to have qualified clinicians accountable to the Company for decisions affecting the member by:

• Individual consultations with providers
• Internal criteria review
• Documented peer-to-peer conversations
• Soliciting feedback from specialists
• Chairing the Medical Advisory Committee

Reviews and approves Company’s clinical review criteria and scripted clinical screening at least annually to ensure their continued appropriateness.
Conducts peer clinical review for all cases where a clinical determination to certify any portion of the requested service cannot be met by an initial clinical reviewer.
Documents and includes specific reasons for the non-certifications.
Conducts, at least weekly, rounds with UR Nurses to discuss cases and provide communication regarding problematic case types.
Conducts peer to peer conversation - clinical reviews for all cases where a certification of any portion of the requested service is not issued through the initial clinical review or initial screening (reconsideration)
Ensures that relevant policies and procedures as well as CMS, accreditation and state and federal program requirements are implemented to achieve effective, efficient, auditable, and compliant operations.
Interprets existing policies and develops new policies based on changes in the healthcare or medical arena.
Provides guidance for all programs related to authorization (pre-certification) of ancillary services and inpatient services and hospitals and skilled nursing facilities.
Provides guidance of the Utilization Management, Quality Management, Disease and Case Management Programs.
Participates in the development, implementation and monitoring of quality improvement projects; for clinical projects, is involved in the selection/approval of clinical quality measures and clinical aspects of performance.
Chairs the Credentialing Committee, Medical Advisory Committee, Peer Review and other committees, as requested.
Provides support for oversight of delegated clinical functions.
Participates in accreditation activities.
Oversees the development and implementation of all peer review activities.
Has authority, accountability and responsibility for denial determinations for lack of medical necessity.
Consults with the board certified specialists in the specialty panel for review of complex utilization issues, as appropriate.
Supports management staff, ensuring timely and consistent responses to members and physicians.
Uses clinical expertise to manage the clinical model, providing medical interpretation and decisions as required.
Identifies and analyzes medical information from multiple sources in order to develop interventions to improve the quality of care and outcomes.
Works with the medical community to assist in the development and maintenance of a strong, quality network of providers.
Reviews provider and member complaints, assist in resolution, and make recommendations for changes.
Notifies Company in a timely manner of an adverse change in licensure or certification status.

Education and/or Experience
M.D. or D.O. from AMA Certified Medical School required.
Board Certified Family Medicine or Internal Medicine – Required.
Minimum 2 years post-graduate experience in direct patient care
Minimum 2 years previous managed care experience required.
Continuing education requirements are met through renewal of licensure by the FL Department of Health.
Minimum 5 years previous practice experience required; Minimum 10 years of previous Managed Care and Medicare health plan experience and knowledge required, showing consistent and progressive responsibility and experience managing others.

Certificates, Licenses, Registrations
Current, unrestricted Florida professional license; board certification (or meets Company’s credentialing standards).

#Florida #Familymedicine #Internalmedicine #Boardcertified #Tampa #Medicaldirector #FL #physician #Humana #bluecross #ModaHealth #HomesteadSmartHealthPlans #PeoplesHealth #Aetna #unitedhealthcare #cigna #floridablue #Avmed #Molinamarketplace #sunshinehealth #capitalhealthplan #oscarhealth #medicalofficer #chiefmedicalofficer #seniordirector #medicare