Medical Director
2 months ago
Management, Inc. by making utilization management determinations, identifying utilization
trends suggesting possible over or under utilization of services and proactively suggesting
improvements to WellMed Medical Management’s utilization management program. The
position will also provide appropriate mentoring and leadership to physicians in the market as
well as develop relationships to support growth and fiscal responsibility.
JOB DESCRIPTION:
The information listed above is not comprehensive of all duties/responsibilities performed.
This job description is not an employment agreement or contract. Management has the
exclusive right to alter this job description at any time without notice.
Performs all duties with physicians and medical group staff in a professional and responsible
manner.
Responds to physicians in a prompt, pleasant and professional manner.
Respects physician, patient, and organizational confidentiality.
Educates medical groups regarding UM policies, procedures and government-mandated
regulations.
Provides quality assurance and education of current medical technologies, review criteria,
accepted practice of medicine guidelines, and UM policies and procedures with counsel
when criterion are not met.
PERSONAL AND PHYSICIAN DEVELOPMENT:
Strives to personally expand working knowledge of all aspects of the UM department.
An active participant in physician meetings.
Orients new physicians to ensure understanding of company policy and resources available
for physician support.
Encourages teamwork and cooperation with medical group staffs in order to prepare for cross
training and float positions.
Assists in the growth and development of subordinates by sharing special knowledge with
others and promotes continued education classes.
Attends continuing education classes to keep abreast of medical advancements and
innovative practice guidelines.
Minimum Required Education, Experience & Skills
Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) degree required.
Board Certified Family Practitioner or Internal Medical Specialist required.
Unrestricted licensed in Texas, Florida, Georgia, or New Jersey required.
Five or more years of clinical practice experience required.
Two or more years of experience in utilization management activities required.
Proficiency with Microsoft Office applications required.
Preferred Education, Experience & Skills
Two years of experience with acute admission experience preferred.
Two years of experience working in a managed care health plan environment preferred.
Unrestricted license in New Mexico preferred (in addition to above).
Bilingual (English/Spanish) fluency preferred.ESSENTIAL JOB FUNCTIONS:
Assists in development and maintaining an efficient UM program to meet the needs of the
health plan members and commensurate with company values.
Educates primary care physicians regarding systems, structures, processes and outcomes
necessary for assurance of regulatory compliance related to market activities.
Develops strategies for improving all aspects of market performance including RAPS,
membership, and medical management.
Participates in case review and medical necessity determination.
Conducts post service reviews issued for medical necessity and benefits determination
coding.
Analyzes aggregate data and reports to primary care physician.
Serves as the liaison between physicians and health plan Medical Directors.
Supervises the functions of Care Coordination.
Assesses the effectiveness of the specialty network to ensure members have access to multi-
specialties within their demographic area.
Represents the providers as an influence to the credentialing committee.
Reviews policies and procedures of credentialing department and offers guidance for revision
and implementation of process.
Educates primary care network and assists in problem resolution.
Assists in development of medical management protocols.
Performs analysis of utilization data and suggests/implements corrective action plans with
network physicians.
Performs all other related duties as assigned.
Customer Service
Oversees and insures physician compliance with UM plan.
Evaluates performance of physicians in regards to established goals and objectives of the company.
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