Health Plan Medical Director

Health Plan Medical Director (MD/DO)

Requisition ID

2025-49450

Category

Physician

Location : Name

Rev Hugh Cooper Admin Center

Location : City

Albuquerque

Location : State/Province

NM

Overview

Presbyterian Healthcare Services exists to improve the health of patients, members and the communities we serve. We are a locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1,600 providers and nearly 4,700 nurses. Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.

The Presbyterian Health Plan (PHP) Medical Director reports to PHP's Senior Medical Director. S/he will be primarily responsible for daily performing medical necessity determinations in partnership with PHPs Utilization Management and is responsible for ensuring that medical protocols and practice guidelines.

This includes utilization management of health care services primarily with the prior authorization staff, participation in formulating complex care coordination, as well as peer-to-peer discussions with community clinicians.

The Medical Director will also provide medical oversight, expertise, and leadership to ensure the delivery of cost-effective, quality healthcare services PHP members.

This position is intended to be conducted within the state of New Mexico; however, remote candidates in other states may be considered. Remote employees may not reside in California, Washington, Illinois, North Dakota, Ohio or New York.

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Qualifications

M.D. or D.O. with board certification. Five years clinical practice experience in pediatric and adult medicine after residency training, currently New Mexico licensed to practice without restriction. Experience in a managed care setting strongly preferred. Experience in the application of evidence-based clinical practice guidelines and resource, utilization, and cost management initiatives. Basic computer literacy and skills (i.e., Microsoft Office, electronic medical records systems. Requires detailed knowledge of medical management principles, including utilization management, case management, retrospective and concurrent review, and prior authorization, in terms of theories and practices both directly and to serve as the resource or educator to other practitioners. Understanding of managed care environment. Experience with Medicare, Medicaid and state programs desirable. Familiarity with National Committee for Quality Assurance (NCQA) and with Health Plan Employer Data and Information Set (HEDIS) principles and requirements desirable.

Responsibilities

Responsibilities:
The following list highlights the opportunities this position offers for professional, cultural, and personal growth:
*Support development and revisions to Medical Policies.
*Assist in initiatives to ensure accessibility of quality, affordable care and coverage for PHPs customers and members
*Provide clinical leadership and promote best practices across the Presbyterian organization
*Manage relationships with providers across the state
*Support population health efforts, including a large population of vulnerable individuals in achieving their best health
*Play an integral role within a fully integrated healthcare system
*Break new ground in medical cost management and population health management
*Support New Mexico in improving the health of its population
*Provide guidance and support for forward-thinking quality improvement initiatives
*Other functions as required

Benefits

We offer more than the standard benefits

Presbyterian employees gain access to a robust wellness program, including free access to our on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more

Learn more about our employee benefits:

https://www.phs.org/careers/why-work-with-us/benefits

Why work at Presbyterian?

As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans. For our employees, we offer a robust wellness program, including free access to our on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more.

Presbyterian's story is really the story of the remarkable people who choose to work here. The hard work of our physicians, nurses, employees, board members and volunteers grew Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system that serves more than 875,000 New Mexicans.

About New Mexico

New Mexico continues to grow steadily in population and features a low cost-of living. Varied landscapes bring filmmakers here from around the world to capture a slice of the natural beauty New Mexicans enjoy every day. Our landscapes are as diverse as our culture - from mountains, forests, canyons, and lakes, to caverns, hot springs and sand dunes.

New Mexico offers endless recreational opportunities to explore and enjoy an active lifestyle. Venture off the beaten path, challenge your body in the elements, or open yourself up to the expansive sky. From hiking, golfing and biking to skiing, snowboarding and boating, it's all available among our beautiful wonders of the west.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.

Compensation Disclaimer

The compensation range for this role takes into account a wide range of factors, including but not limited to experience and training, internal equity, and other business and organizational needs.

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