Associate Medical Director - Health Plan

Parkland Health

About The Position

The Associate Medical Director reviews prior authorization and appeal requests to approve or deny claims payment based on medical necessity. The role oversees medical coordination needed for effective utilization and quality management across the health plan network and supports PCHP clinical functions, including Utilization Management, Quality Management, Clinical Policy, Technology Assessment, Credentialing, Population Health, and Fraud, Waste and Abuse. The position helps ensure comprehensive, high-quality care for plan members in accordance with managed care and PCHP policies, while monitoring clinical care to promote optimal health outcomes and cost-effective care. The Associate Medical Director provides clinical oversight for assigned activities, contributes to medical policies and evidence-based clinical standards, evaluates provider performance and qualifications, and assists with oversight of pharmacy benefits and fraud, waste, and abuse programs. The role also participates in organizational goal-setting, member and provider education, process improvement, and managed care and community committees. The position carries administrative and supervisory responsibilities, including budget and goal monitoring and employee management.

Requirements

Completion of an ACGME- or AMA-approved residency in a specialty appropriate to the PCHP population.
At least five years of clinical practice experience in a specialty relevant to the care of PCHP members.
At least three years of experience caring for populations relevant to the PCHP population or in managed care.
Substantial experience and expertise in developing medical policies, procedures, and programs.
Demonstrated success implementing utilization and quality improvement strategies or techniques and experience with physician behavior modification.
Current license to practice medicine in Texas.
Meet and maintain Texas licensing and registration requirements applicable to Managed Care Medical Directors.
Philosophical orientation to the managed care concept of health delivery and working knowledge of managed care principles.
Strong leadership, organizational, interpersonal, and verbal communication skills, including the ability to work efficiently and communicate with executive management, physician groups, community and provider organizations, and people from diverse socioeconomic backgrounds.
Working knowledge of Texas Medicaid regulations and their interpretation.
Effective supervisory, administrative, and management skills, including computer literacy.
Ability to demonstrate patient-centered and patient-valued behaviors.
Knowledge of care coordination and collaboration, population health, social determinants of health, clinical evaluation of evidence-based care, and value-based purchasing.
Familiarity with the roles of pharmacy and behavioral health in managing health care.
Ability to create, review, and interpret treatment plans; adapt to changing priorities; handle confidential information; negotiate; and remain calm under pressure.
Ability to apply medical knowledge and principles to business challenges to achieve member, business, and quality outcomes.
Attention to detail and a hands-on approach.

Nice To Haves

Qualifications to perform clinical oversight for health plan services, including relevant education, training, or professional experience in medical or clinical practice.
Past participation in a managed care utilization management committee.

Responsibilities

Review prior authorization and appeal requests to approve or deny claims payment based on medical necessity.
Conduct peer-to-peer calls as needed to support the utilization management process.
Provide clinical oversight for assigned utilization management, disease management, and quality management activities.
Participate in developing medical policies and procedures for coverage and authorization, as well as clinical standards and guidelines based on evidence-based medicine.
Analyze data to develop health care provider profiles and determine whether physician performance is acceptable.
Review provider applications and qualifications, participate in reviews of providers who fail to meet standards, and conduct site and medical-record reviews as appropriate.
Assist the Senior Medical Director and Pharmacy Director in overseeing and administering the PCHP pharmacy benefit, including coordination between medical and pharmacy benefits.
Assist the Senior Medical Director in overseeing, evaluating, and administering clinical aspects of PCHP fraud, waste, and abuse programs.
Participate in developing, implementing, and monitoring PCHP annual goals and objectives that support Parkland’s mission and objectives.
Help identify member and provider education and health-promotion needs; assess, develop, and evaluate provider education programs as needed.
Represent PCHP in clinical activities with relevant state and local bodies when assigned by the Chief Medical Officer or Senior Medical Director.
Identify and analyze opportunities to improve job design, work processes, and workflows, and implement appropriate changes to improve effectiveness, productivity, and efficiency.
Serve as chairperson or member of managed care committees and participate in community and interdisciplinary committees as assigned.
Stay current with developments and trends in the field and apply relevant knowledge to work practices.
Maintain knowledge of applicable laws, rules, regulations, policies, and guidelines; develop internal controls that promote compliance.
Develop and monitor annual budgets and departmental goals and objectives.
Select, train, schedule, motivate, supervise, and evaluate employees; recommend disciplinary actions up to and including termination; and support employee development.