Senior Medical Director

1 month ago

Tulsa, United States CommunityCare Full time

JOB SUMMARY:

Responsible for overseeing Care Management and Utilization Management segments of the health care delivery area. This key Executive role provides leadership to a large team of nurses, coordinators, and other personnel to determine approvals/denials of claims as well as direction to several important initiatives as requested. The Senior Medical Director has current, relevant knowledge and/or has current, relevant clinical expertise to manage cases under review, including the current, evidence-based clinical guidelines and novel treatments for the medical or behavioral health conditions, diseases, treatments, or procedures under consideration in order to render an initial utilization review determination or an appeal determination. Emphasis is placed on quality improvement and member safety, and the Senior Medical Director designs and implements programs in support of this effort.


KEY RESPONSIBILITIES:

  • Provide oversight for clinical operations and decision making for CommunityCare programs.
  • Responsible for ensuring the training and quality of clinical staff.
  • Responsible for initial utilization management determinations. Work with team of nurses and other staff on pre-authorization and retrospective authorization requests for services.
  • While performing utilization review, routinely applies sound clinical judgement in consideration of an individual member’s clinical needs.
  • Provides directions to multifunctional care management teams.
  • Assist in supervisory management activities.
  • Support and guide quality improvement activities and develop programs for strategic implementation.
  • Research and development of practice guidelines, including those dealing with routine, preventative health care and their implementation at the provider level.
  • Management of and/or participation in internal company committees as requested.
  • Perform timely and responsive Peer to Peer discussions as needed at the provider’s convenience.
  • The Senior Medical Director is available for real time consultation with the initial clinical reviewers, either before and/or after making the review determination.
  • If not involved with the initial denial determination, renders an appeal determination on medical, behavioral or drug utilization management cases under review.
  • Participate in the interview process for key clinical staff positions.
  • Participate in annual evaluation process of key clinical staff.
  • Direct the regional efforts of CommunityCare Managed Healthcare Plans of Oklahoma with emphasis on concurrent review of inpatient hospital stays.
  • Maintains excellent communications with the networks, with special attention to our owner networks.
  • Maintains effective relationships with providers and provider organizations.
  • Perform other special projects and duties as assigned by the executive staff of CommunityCare Managed Healthcare Plans.


QUALIFICATIONS:

  • Ability to effectively lead, direct and supervise others.
  • Ability to converse and write fluently in English.
  • Successful completion of Health Care Sanctions background check.
  • Qualified, as determined by the Chief Medical Officer, to render a clinical opinion or determination about the medical or behavioral health condition, procedures, or treatment under review.


EDUCATION/EXPERIENCE:

  • Graduation from accredited medical school (Doctor of Medicine or Doctor of Osteopathic Medicine) with residency-training in a relevant specialty.
  • Minimum 5 years direct patient care and clinical experience in their specialty.
  • Current and active unrestricted* license to practice medicine in the State of Oklahoma.
  • Must be board certified and maintain certification.
  • Post-graduate management training is a plus.
  • Demonstrated leadership skills and experience is a plus.
  • Prior experience at health plan company preferred.
  • License is of the type and scope that permits them to apply their clinical judgement in consideration of an individual member’s clinical needs to render an initial or appeal utilization review determination.
  • For Clinical Peer Review, licensed as either a Doctor of Medicine or Doctor of Osteopathic Medicine.

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