Medical Director
2 months ago
Medical Professional(s) responsible for direction and oversight of healthcare services provided to Plan members to ensure the delivery of cost-effective, quality services. The Medical Director shall be responsible for Medical Direction of all activities of the Quality Management and Utilization Management Programs of The Health Plan. This will be a Dyad relationship with the Directors of Utilization and Quality Management and Pharmacy Management.
Required:
- Active physician license without restriction.
- Meets all THP credentialing requirements.
- Three years managed care experience in HMO setting preferred.
- Board certification.
- Minimum of five years post graduate clinical experience.
Desired:
- Basic computer literacy.
- Prior leadership roles while in clinical practice is desirable.
- Demonstrated ability to work in unison with other professionals and non-professionals in a respectful and harmonious manner.
Responsibilities:
- Provide Physician oversight for activities related to the company’s Utilization Management, Disease Management and Quality Management programs ensuring compliance with NCQA, Medicare, Medicaid, and other regulatory entities. Play an active role in preparing for related audits and information requests from such entities.
- Establish the highest standards of best medical practices for care provided to members through participation in the development of clinical practice guidelines and selection and procurement of suitable proprietary criteria and clinical pathways.
- Provide physician education regarding Health Plan utilization management and quality management protocols and initiatives. Work with individual physicians or physician groups to achieve acceptance and understanding of Health Plan medical appropriateness criteria, practice guidelines and patient care programs.
- Carry out specific functions as outlined in the Utilization Management Program including:
- a. Play a leadership role in the development and implementation of the Utilization Management Program including assisting in the development of the annual work plan and program evaluation. Serve as chairperson and or member of various utilization management committees as set forth in the Utilization Management Program Description.
- b. Review clinical utilization and the delivery of acute care to members on a daily basis. Maintain daily interaction with hospital review, case managers, care managers, disease managers, pharmacy managers, claims managers and other staff.
- c. Review all cases where medical appropriateness is questioned and provide overall responsibility for authorization or non-authorization based on medical appropriateness of the health care services requested.
- d. Available to communicate telephonically with practitioners in case review matters.
- e. Available as needed to provide twenty-four hour coverage for case review matters.
- f. Actively participates in the functioning of the plan appeal and grievance procedures.
- Carry out specific functions as outlined in the Quality Management Program including:
- a. Play leadership role in the development and implementation of the Quality Management Program including assisting in the development of the annual work plan and program evaluation. Serve as chairperson and/or member of various quality management committees as set forth in the Quality Management Program Description including but not limited to the Quality Improvement Committee, the Credentials Committee, the Pharmacy and Therapeutics Committee, the Transplant and Technology Committee, Utilization Management Committee and other related committees.
- b. Monitors, evaluates, and validates clinical quality issues and refers them to the appropriate internal staff, committees or institutional regulatory bodies.
- c. Collaborates in organizing a continuous quality improvement mechanism for The Health Plan and in identifying specific clinical goals and objectives for focus or priority.
- d. Acts as a guide and resource to the Quality Management Program in the collection and analysis of data related to quality studies and surveys. Participates in the qualitative analysis of data to identify barriers and corrective actions as well as re-evaluation after intervention.
- Works directly with Network Development staff to develop and coordinate effective provider education/intervention programs including providing input into provider training and education programs, review of provider manuals and direct contact with providers as needed.
- Perform other duties and special projects as assigned to accomplish the goals of the organization.
-
Medical Director
3 months ago
Wheeling, United States The Health Plan of West Virginia Inc Full timeJob DescriptionJob DescriptionMedical Professional(s) responsible for direction and oversight of healthcare services provided to Plan members to ensure the delivery of cost-effective, quality services. The Medical Director shall be responsible for Medical Direction of all activities of the Quality Management and Utilization Management Programs of The Health...
-
Assistant Director of Nursing
6 days ago
Wheeling, United States Franciscan Ministries Full timeOverview: Assistant Director of NursingHighly Competitive Salary Addolorata Villa Wheeling, ILAward Winning Senior Living Community We love our Nursing Staff! THAT’S WHY WE OFFER… PayActiv – Immediately access up to 50% of your earned payTax Free Student Loan ForgivenessGreat Health PlansEmployer Funded Health Savings AccountCompany Paid Life...
-
Director, Case Management
3 months ago
Wheeling, United States The Health Plan of West Virginia Inc Full timeJob DescriptionJob DescriptionThe Director of Case Management provides leadership, management, oversight, and assessment of all aspects of clinical program management and is responsible for ensuring quality provision of member driven care continuum programs while ensuring delivery of essential services that address the total health care needs of The Health...
-
Assistant Director of Nursing
1 week ago
Wheeling, United States Franciscan Ministries Full timeOverview: Assistant Director of NursingHighly Competitive Salary Addolorata Villa Wheeling, ILAward Winning Senior Living Community We love our Nursing Staff! THAT’S WHY WE OFFER… PayActiv – Immediately access up to 50% of your earned payTax Free Student Loan ForgivenessGreat Health PlansEmployer Funded Health Savings AccountCompany Paid Life...
-
Assistant Director of Nursing
2 weeks ago
Wheeling, United States Franciscan Ministries Full timeOverview: Assistant Director of NursingHighly Competitive Salary Addolorata Villa Wheeling, ILAward Winning Senior Living Community We love our Nursing Staff! THAT’S WHY WE OFFER… PayActiv – Immediately access up to 50% of your earned payTax Free Student Loan ForgivenessGreat Health PlansEmployer Funded Health Savings AccountCompany Paid Life...
-
Assistant Director of Nursing
1 week ago
Wheeling, United States Franciscan Ministries Full timeOverview: Assistant Director of NursingHighly Competitive Salary Addolorata Villa Wheeling, ILAward Winning Senior Living Community We love our Nursing Staff! THAT’S WHY WE OFFER… PayActiv – Immediately access up to 50% of your earned payTax Free Student Loan ForgivenessGreat Health PlansEmployer Funded Health Savings AccountCompany Paid Life...
-
Director of Nursing Operations
7 days ago
Wheeling, Illinois, United States Franciscan Ministries Full timeJob SummaryWe are seeking a highly skilled and experienced Director of Nursing Operations to join our team at Franciscan Ministries. As a key member of our leadership team, you will be responsible for overseeing the daily operations of our Nursing Department, ensuring the delivery of high-quality patient care and services.Key ResponsibilitiesLeadership and...
-
Director of Nursing Operations
7 days ago
Wheeling, Illinois, United States Franciscan Ministries Full timeJob SummaryWe are seeking a highly skilled and experienced Director of Nursing Operations to join our team at Franciscan Ministries. As a key member of our leadership team, you will be responsible for overseeing the daily operations of our Nursing Department, ensuring the delivery of high-quality patient care and services.Key ResponsibilitiesLeadership and...
-
Medical Billing Assistant
3 months ago
Wheeling, United States Russell Nesbitt Services Inc. Full timeJob DescriptionJob DescriptionJob descriptionPrimary Duties: Serve as primary liaison and subject matter expert for Medicaid Waiver billing and support. Help prepare monthly financial statements and prepare work papers for audits. Secondary Duties: Act as the backup for the accounting department as needed, specific emphasis on billing and utilization...
-
Assistant Director of Nursing
2 days ago
Wheeling/Illinois/US Franciscan Ministries Full timeOverview: Assistant Director of NursingHighly Competitive Salary Addolorata Villa Wheeling, ILAward Winning Senior Living Community We love our Nursing Staff! THAT’S WHY WE OFFER… PayActiv – Immediately access up to 50% of your earned payTax Free Student Loan ForgivenessGreat Health PlansEmployer Funded Health Savings AccountCompany Paid Life...
-
Assistant Director of Nursing
1 day ago
Wheeling, IL, United States Franciscan Ministries Full timeOverview: Assistant Director of NursingHighly Competitive Salary -Addolorata Villa Wheeling, ILAward Winning Senior Living Community - -We love our Nursing Staff! - THAT'S WHY WE OFFER--- - - PayActiv - Immediately access up to 50% of your earned pay Tax Free Student Loan Forgiveness Great Health Plans Employer Funded Health Savings Account Company...
-
Assistant Director of Nursing
1 week ago
Wheeling, IL, United States Franciscan Ministries Full timeOverview: Assistant Director of NursingHighly Competitive Salary Addolorata Villa Wheeling, ILAward Winning Senior Living Community We love our Nursing Staff! THAT’S WHY WE OFFER… PayActiv – Immediately access up to 50% of your earned payTax Free Student Loan ForgivenessGreat Health PlansEmployer Funded Health Savings AccountCompany Paid Life...
-
Manager, Utilization Management
2 weeks ago
Wheeling, United States The Health Plan of West Virginia Inc Full timeJob DescriptionJob DescriptionA Manager within Clinical Services is responsible for overseeing day to day operation of the clinical staff for Medical Utilization Management for all lines of business. They are responsible for ensuring proper staffing levels, work assignments, performance evaluation of staff, serving as a subject matter expert on benefits,...
-
Podiatry Residency Specialist
2 months ago
Wheeling, United States WVU Medicine Full timeWelcome! We're excited you're considering an opportunity with us! To apply to this position and be considered, click the Apply button located above this message and complete the application in full. Below, you'll find other important information about this position. MINIMUM QUALIFICATIONS: EDUCATION, CERTIFICATION, EXPERIENCE, AND/OR LICENSURE: 1. Bachelor's...
-
Podiatry Residency Specialist
2 months ago
Wheeling, United States WVU Medicine Full timeWelcome! We're excited you're considering an opportunity with us! To apply to this position and be considered, click the Apply button located above this message and complete the application in full. Below, you'll find other important information about this position. MINIMUM QUALIFICATIONS: EDUCATION, CERTIFICATION, EXPERIENCE, AND/OR LICENSURE: 1. Bachelor's...
-
Regional Sales Manager
2 weeks ago
Wheeling, United States CommuniCare Health Services Corporate Full timeRegional Sales Manager - Northern West Virginia/Pennsylvania Due to continued growth, CommuniCare Health Services is currently recruiting for a Regional Sales Manager to cover our facilities in Northern West Virginia and Pennsylvania. PURPOSE/BELIEF STATEMENT The Regional Sales Manager's mission is to develop sales strategies to promote census growth in...
-
Call Center Coordinator
5 days ago
Wheeling, West Virginia, United States The Health Plan of West Virginia, Inc. Full timeJob Summary:The Customer Service Coordinator position is responsible for assisting the Manager and Director with daily operational activities relating to the call center, which may include: claims payment issues, call monitoring, and providing team guidance and support.Key Responsibilities:Assist with Claims and Payment Issues: Collaborate with the Manager...
-
Regional Sales Manager
5 days ago
Wheeling, United States CommuniCare Health Services Corporate Full timeRegional Sales Manager - Northern West Virginia/Pennsylvania Due to continued growth, CommuniCare Health Services is currently recruiting for a Regional Sales Manager to cover our facilities in Northern West Virginia and Pennsylvania. PURPOSE/BELIEF STATEMENT The Regional Sales Manager's mission is to develop sales strategies to promote census growth in...
-
Regional Sales Manager
3 months ago
Wheeling, United States CommuniCare Health Services Corporate Full timeRegional Sales Manager - Northern West Virginia/Pennsylvania Due to continued growth, CommuniCare Health Services is currently recruiting for a Regional Sales Manager to cover our facilities in Northern West Virginia and Pennsylvania. PURPOSE/BELIEF STATEMENT The Regional Sales Manager's mission is to develop sales strategies to promote census growth in...
-
Clinical Delegation Oversight Nurse Coordinat
3 months ago
Wheeling, United States The Health Plan of West Virginia Inc Full timeJob DescriptionJob DescriptionUnder the supervision of the Manager, Clinical Compliance, is responsible for enforcing that delegated contracts to perform clinical functions in utilization management and population health management on behalf of the Plan is in compliance with all regulatory/accreditation requirements. Reviews and audits policies, procedures,...
