Responsibilities

Job Descripton: Reporting to the Interim 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. The Medical Director will provide leadership for the above-mentioned 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 hold an active, unrestricted, and current license to practice medicine and are board- certified by a specialty board approved by the American Board of Medical Specialties or the Advisory Board of Osteopathic Specialists. 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 will play a key role in the direction and execution of the PHP success in Nevada, Texas, and other markets as indicated related to the delivery of medical services in a population management environment. This 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. Furthermore, this medical leader will, as necessary, provide the skills and experience necessary in working with the marketing and sales department to assist in new membership growth and as necessary key account retention.

The Medical Director will be expected to 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.

Qualifications

Duties & Responsibilities:

• Collaborates to implement new and improve existing disease management, care management, and care integration programs related to member benefit design, provider network composition, and population health.
• Integrates medical services across the PHP service and delivery system to ensure the best possible quality of care for members.
• Provides leadership to the company in the areas of strategy execution and implementation of effective and efficient care management programs, including Utilization Management, Case Management, Disease Management, Risk Adjustment, and Pharmacy Management.
• Provides leadership in regard to the analysis of medical care cost and utilization data and the development and implementation of programs to mitigate adverse cost trends.
• Leads and manages the development of techniques to effectively correct identified and anticipated utilization problems while assuring that members receive the care they need.
• Provides leadership in direction and oversight functions to utilization management staff designed to achieve best in class performance as defined by identified metrics.
• Oversees, directs, and supports the rendering of utilization management decisions and is responsible for peer-to-peer clinical review at all levels of the company that maximize benefits for members while pursuing and supporting organization objectives.
• Supports quality improvement programs and ensures that medical policies and procedures are implemented to comply with regulatory and accreditation agencies such as URAC/NCQA, CMS, and DHS and serves as the chairperson or member of the health plan's quality improvement, medical advisory, credentialing, and pharmacy & therapeutics committees.
• Responsible for development and attainment of the annual budget for Medical Management including the utilization management, quality improvement, risk adjustment, and pharmacy.
• Interfaces with key physician leaders in the PHP services areas and states and ancillary providers and executives to maintain a positive working relationship with network contracted partners; at the same time, takes the opportunity to reduce cost/expenses and change certain provider behaviors in support of the health plans goals and objectives.
• Performs job duties and responsibilities in a manner consistent with PHP, policies, and procedures.

Regulatory Requirements:

• Doctorate Degree in Medicine 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 or the Advisory Board of Osteopathic Specialists.
• An active, unrestricted license or certification to practice medicine or a health profession in a state or territory of the United States.
• Current and active without restrictions in states PHP services (Nevada, Florida, and Texas) and free of sanctions from MD Medicaid or Medicare
• Unless expressly allowed by state or federal law or regulation, are located in a state or territory of the United States when conducting a peer clinical review
• Are qualified, as determined by the Chief Medical Officer or clinical director, to render a clinical opinion about the medical condition, procedures, and treatment under review; and holds a current and valid license in the same licensure category as the ordering provider; or as a Doctor of Medicine or Doctor of Osteopathic Medicine
• Previous Associate Medical Director/Medical Director experience preferred
• Minimum five years clinical practice and post-graduate experience in direct patient care
• Familiarity with Managed Care Principles
• Familiarity with HEDIS/CAHPS/STARS/HOS/NCQA/URAC
• Ability to effectively communicate in English, both verbally and in writing.
• 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.
• For physical demands of position, including vision, hearing, repetitive motion, and environment see following description. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position without compromising patient care.