REMOTE - Medical Director, Health Plan

Join Martin's Point Health Care an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. taking care of ourselves and others, continuous learning, helping each other, and having fun - Position SummaryThe Medical Director (MD) provides clinical leadership and direction to the utilization & care management functions of Martin’s Point’s Health Plans. The MD works collaboratively with other plan functions that interface with Medical Management such as Health Management, Compliance and Appeals, , Network Management, Member Services, benefits & claims management, and Compliance. In this role, there is the opportunity to assist in or drive short and long-range clinical programming, quality management, and external relationships. The Medical Director reports to the Vice President Health Plan Medical Director and works closely with the other Health Plan leaders.## Responsible and accountable to the Health Plan Medical Director for helping to manage health plan medical costs by assuring clinically appropriate health care delivery for health plan products and services utilizing Evidence-Based Guidelines to ensure the right service at the right time and place for each member * Performs medical necessity reviews of requests for health plan-covered services (benefits). Reviews disputes and appeals of said services for clinical appropriateness and in compliance with government program rules * Contributes to case reviews to ensure the quality and safety of care and services delivered to Martin’s Point Health Plan members. * Assists in the construction of the annual Utilization Management, Care Management, and Disease Management Program Descriptions and works to ensure the programs meet accreditation and regulatory standards (e.g. NCQA, CMS, TRICARE) * Participates in medical policy review and policy development. * Works with Informatics, Network Management, and Medical Economics to create and maintain a system where Network providers are properly assessed in regard to cost management and develops a plan and schedule for communication and solutioning with outliers. * Provides support to Health Plan risk adjustment activities as needed. * Is conversant with Health Plan key performance metrics, in particular utilization and cost management goals, MLR , inpatient days/1000, SNF days/1000, and clinical quality improvement (QI) objectives, including HEDIS and how to drive improvement in these areas **Board certified physician with post-graduate experience in direct patient care required * Medical leadership in, or focused activity of, a Health Plan (preferred) * Knowledge of process improvement tools * Experience in Health Plan utilization management * Active and unrestricted license to practice medicine in Maine or New Hampshire; Deep knowledge and practical understanding of Health Care systems and Managed Care concepts * Knowledge and deep commitment to performance-based Health Plan systems * Willingness to explore innovative methods of providing medical management * This position is not eligible for immigration sponsorship. ****Martin's Point complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact ** ** ** Remote working/work at home options are available for this role.