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Medical Director, UM Review, Family Medicine
4 months ago
Responsibilities
:Provide organizational leadership in the operational areas of care management, utilization review, appeals, quality improvement and related policy and practice initiatives in collaboration with the Corporate Medical Director(s), Senior Medical Directors, Utilization Management and the Vice President, Medical Affairs.
The following responsibilities are in regards to enrollees with medical conditions and their providers:
Identifying and implementing evidence-based practice guidelines throughout the provider network. Overseeing the quality of clinical care for network and non-network providers. Engaging the provider network in Continuous Quality Improvement through the diffusion of practice standards, and through an internal quality assurance program that measures network. Provider performance against standards of high quality, especially the performance standards embodied in the HEDIS program. Assuring a high-performing Medical Management system that adheres to the terms of contracts and all relevant regulatory requirements. Utilizing evidence based standards in making coverage determinations.Accountabilities:
Ensures the provision of quality and clinically sound services to all Enrollees by associates and Providers. Serves as medical advisor and manager for all clinically related activities. Assures that organization medical policies and procedures adhere to contractual obligations. Performs clinical case reviews in conjunction with Medical Excellence Department. Demonstrates knowledge of prescribed and established medical procedures and practices. Maintains familiarity with federal, state and local regulations that may pertain to the medical and clinical operations. Provides leadership in the development and implementation of medical policy as it relates to health management. Maintains compliance with applicable regulatory guidelines, AmeriHealth Caritas clinical policies and procedures, and contractual obligations. Manages day-to-day operations and monitors the integration and processing of members to optimize appropriate use of behavioral and physical health services. Participates with Quality Improvement and Medical Excellence in the identification and analysis of medical and behavioral health information in order to develop interventions to improve clinical effectiveness of medical management strategies. Works closely with a multidisciplinary team to ensure behavioral health management and quality management programs are meeting contractual obligations. Works with the leadership of the Quality Improvement and Medical Excellence departments to develop competent clinical staff. Trains staff on medical issues and provide consultation to staff as appropriate. Assists IHCM Managers in assessing members’ need for case management services. Attends case management meetings and monthly rounds as scheduled. Collaborates with the integrated case management team, during scheduled meetings and informally as needed. Thoroughly documents all care coordination activity in the member medical record in the electronic case management documentation system. Adheres to AmeriHealth Family of Companies (ACFC) policies and procedures and supports and carries out the ACFC mission and values. Other duties as assigned.Education/ Experience:
Able to work Monday through Friday from 8:30a EST to 5:00p EST. Call and holiday coverage are based on business needs. Doctor of Medicine. Must be licensed to practice in any state licensed in as a medical director. Additional state licensure required in all states where ACFC has a line of business with those licensure applications expected to be submitted within 3 months of employment. Must be Board Certified in Family Medicine. 3+ years in on or a combination of the following: Full-time experience as an administrator in a Medicare or state-level Medicaid program, Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), large Health Care Organization, health plan or any combination thereof, or Full-time medical facility administration or medical facility management experience. 3+ years of State Management organization (SMO) experience preferred. 5+ years clinical practice experience. Strong written and oral communication skills required. Demonstrated competency in use of healthcare data. Demonstrated excellent interpersonal communication skills and presentation skills. Experienced in conflict resolution and negotiation. Understanding of and expertise in quality improvement and medical economics. Strong leadership skills. Excellent analytical and problem solving skills. Proficiency utilizing MS Office (Word, Excel, Outlook, Teams), SharePoint, Internet search engines and applications. Demonstrated ability to access department’s work quality and develop / implement process improvements to achieve regulatory and oversight compliance.Diversity, Equity, and Inclusion
At AmeriHealth Caritas, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.
We keep our associates happy so they can focus on keeping our members healthy.
Our Comprehensive Benefits Package
Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.
Generous paid time off, including holidays and volunteer events.
Employer-matched 401(k) and additional non-elective contributions, starting on day one.
Medical, dental, and vision plans — with coverage starting on day one.
Employee assistance programs, fitness reimbursements, nutrition counseling, and more.
Employer paid life insurance, with opportunities to purchase additional coverage.
Employer paid short-term disability coverage and long-term disability coverage.
Tuition assistance, including reduced tuition at certain schools.
Financial assistance with adoption, including paid time off.
Flexible spending and health savings accounts to pay for qualified expenses.
Discount programs on entertainment, travel, and more.
