Medical Director

Medical Director

Requirements

• Medical Doctor or Doctor of Osteopathy
• 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
• Current Indiana state license as a MD or DO without restrictions, limitations, or sanctions from government programs
• Utilization Management experience and knowledge of quality accreditation standards preferred
• Actively practices medicine
• Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is advantageous
• Experience treating or managing care for a culturally diverse population preferred

Responsibilities

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

Preferred Qualifications

• Utilization Management experience and knowledge of quality accreditation standards preferred
• Experience treating or managing care for a culturally diverse population preferred