Community & State Medical Director - Colorado
About The Position
The Medical Director provides leadership to the Health Plan’s enterprise healthcare value effort and bed-day management processes, ensuring appropriate decisions are made that are in alignment with insurance product benefits and the level of care for members. Accountability includes oversight of medical & clinical processes with a focus on implementing plans of care that meet accepted guidelines and protocols and ensure that optimal and appropriate medical & clinical services are provided. The Medical Director educates and interacts with network and group providers as well as clinical and case management staff regarding utilization practices and effective resource management. The Medical Director is accountable to manage resource allocation as is applicable to medical management practices under his or her scope of responsibility.
Requirements
- 10+ years of medical experience
- Active/unrestricted Medical License
- Active Board Certified in an ABMS/AOBMS specialty
- Broad and comprehensive knowledge of medical management principles and insurance products for multiple and varied lines of business in a managed care environment
- Solid knowledge of community health care environment, the provider network and managed care contracting processes
- Solid understanding of managed care systems, quality improvement and risk management
Nice To Haves
- 8+ years of progressively responsible management experience preferably in a managed care setting
- Demonstrated excellent medical management and leadership skills
- Demonstrated excellent communication skills
- Proven team player and strong teambuilding skills
- Proven creative problem-solving skills
- Proven good skills in making presentations and teaching
- Proven solid organizational and prioritization skills
Responsibilities
- Conduct coverage review based on individual member plan documents, and national and proprietary coverage review guidelines, render coverage determinations, and discuss with requesting providers as needed in peer-to-peer telephone calls
- Communicate and collaborate with network and non-network providers in pursuit of accurate and timely benefit determinations for plan participants; educates providers on benefit plans and UHC medical policy and utilization review guidelines
- Is available and accessible to the UM & Care Management staff throughout the day to respond to inquiries while serving as a clinical resource, coach, and leader
- Document clinical review findings, actions, and outcomes in accordance with Health Plan policies, and regulatory and accreditation requirements
- Actively participate in identifying and resolving problems and collaborates in process improvements that may include other Health Plan departments as well as key community stake holders and leaders
- Participate in senior medical management strategy development and implementation to ensure that appropriate care and services provided to members meet best practice standards as well as regulatory compliance requirements
- Support overall market, regional, and corporate goals to ensure continued growth and affordability of the Health Plan
- Review inpatient cases and is accountable for successful bed-day management that meets established company goals
- Analyze utilization data to identify trends and opportunities for process improvement related to medical treatment (inpatient and outpatient)
- Participate in HPRs for employer groups
- Participate in Appeals & PA
- Participate and support population health strategies where applicable
- Ability to contribute to the organization’s efforts to eliminate racial and ethnic disparities in organizational performance and support cultural awareness
Benefits
- a comprehensive benefits package
- incentive and recognition programs
- equity stock purchase
- 401k contribution
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What This Job Offers
Job Type
Full-time
Career Level
Senior
