Medical Director

Position Title: Medical Director

Work Location: Remote - Nationally Sourced

Assignment Duration: 6 months with potential to extend or convert

Work Schedule: 8 am - 5 pm in candidate's time zone (EST, CST, PST)

Position Summary:

* Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit.

Key Responsibilities:

* Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities.

* Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality decision making.

* Supports effective implementation of performance improvement initiatives for capitated providers.

* Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members.

* Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.

* Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership.

* Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes.

* Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals.

* Participates in provider network development and new market expansion as appropriate.

* Assists in the development and implementation of physician education with respect to clinical issues and policies.

* Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components.

* Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care.

* Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality.

* Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment.

* Develops alliances with the provider community through the development and implementation of the medical management programs.

* As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues.

* Represents the business unit at appropriate state committees and other ad hoc committees.

* May be required to work weekends and holidays in support of business operations, as needed.

* Performs other duties as assigned

* Complies with all policies and standards

Qualification & Experience:

* Medical Doctor or Doctor of Osteopathy

* Utilization Management experience

* Board certification in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Association's Department of Certifying Board Services (Psychiatry if Behavioral Health)

* Current state medical license without restrictions

* Course work in Health Admin, Financing, Insurance preferred

* Experience treating or managing care for culturally diverse population preferred