Medical Director

JOB PURPOSE:

The Medical Director will lead the Medical areas of the company, which include: Precertification, Case Management and Medical Audit to ensure the development of a solid and scalable operational platform with the objectives of ensuring our members receive optimal medical care within policy guidelines  and delivering superior service. The Medical Director must have outstanding communication and interpersonal skills, as well as the ability to manage multiple projects and implement high quality work processes.

ESSENTIAL JOB DUTIES AND RESPONSIBILITIES

• Establish the medical strategy the company and ensure it is consistently applied throughout the different medical areas
• Lead the medical areas in defining and executing high quality and consistent work processes through internal training and continuous process improvement
• Review and approve high-cost services, such as air ambulance, transplant, chemotherapy/radiation, etc.
• Performs benefit-driven medical necessity reviews for coverage, case management, and claims resolution purposes using benefit plan information, clinical guidelines and clinical best practices.
• Ability to gain an in-depth understanding of the operation to effectively review and optimize internal processes that result in efficiency gains and cost reduction within the medical areas
• Champion and implement solid medical decision-making practices across the operation to enhance the level of service
• Define key performance indicators and supervise department’s budget and staffing
• Work with the company’s Actuary on continuous evaluation and updating of standards/guidelines and best practices
• Ensure medical guidelines are applied consistently
• Deliver outstanding service to internal and external customers
• Develop staffing and resource models to balance workload and ensure teams are up to date with their assignments
• Participate in the Policy Review process and propose changes based on medical perspective
• Foster working relationships with agents and communicate with them as appropriate via phone calls, email, seminars and conventions
• Collaborate closely with all areas of the business, such as Client Services, Operations, Providers, Actuarial, Legal, Marketing and Sales
• Direct the Case Management process to ensure that all related activities meet predefined performance standards and procedural guidelines
• Oversee and direct cost control activities within medical areas to include: defining negotiation strategy, goals and expectations for physicians; monitoring savings; and establishing UCR guidelines
• Lead the team of medical audit; Establish the communication protocol to enhance collaboration between audit and other areas of the Precertification Team
• Acts as coach and motivator lending support and guidance to staff; ensures that medical staff is properly trained by providing internal and external training opportunities
• Lead internal educational programs, such as medical terminology and CPT training, to enhance employee knowledge leading to improved service and productivity levels
• Oversee, define requirements and support the on-call process
• Define and set approval levels required for the various types of cases
• Define overtime criteria to include qualifications, staff selection and approval requirements
• Research, propose and approve tools to enhance productivity and accuracy of medical data 

DESIRED MINIMUM QUALIFICATIONS

• Strong knowledge of medical conditions and their potential cost impact
• Strong knowledge of managed care policies and principles
• Able to measure risk and potential downside to claims decisions
• Able to lead cross-functional teams  
• Experience with change management principles
• Strong analytical skills and detailed oriented
• Able to work independently. Excellent time management skills and ability to prioritize
• Excellent public speaking/presentation skills
• Strong commitment to service and quality
• Bilingual (must be fluent in English and Spanish) - speak, read and write, Portuguese a plus
• Familiar with health insurance principles and guidelines
• Familiar with Milliman guidelines
• Experience in participating and/or developing medical distinction programs 

EDUCATION AND EXPERIENCE

• 10 years of medical experience in hospitals and/or health insurance companies (preferably with international major medical products)
• 5 years of management experience or equivalent experience implementing projects
• Track record leading teams to deliver superior service in fast-paced entrepreneurial company
• Medical Doctor degree (U.S. or foreign)