Medical Director - Benefit/Utilization Management

CareOregon•WFH (Oregon), OR

4d•$294,570 - $360,030•Remote

About The Position

This position is responsible for oversight of clinical and wellness programs and initiatives in support of CareOregon members. Areas of focus may include benefit management, benefit utilization, quality assurance, case management, disease management, pharmacy, or other areas. This is a 0.8 position with benefits. The hiring range listed would be pro-rated to reflect 0.8.

Requirements

Board-certified medical doctor or doctor of osteopathy in one of the primary care specialties, including obstetrics/gynecology (Internal Medicine, Family Practice, Emergency Medicine, or Pediatrics preferred)
Licensed physician (MD or DO) in the State of Oregon
Minimum 3 years’ physician experience
Clinical knowledge of the management of diverse medical problems
Basic knowledge of applicable regulatory and contractual requirements for Medicaid, Medicare and commercial insurance
Understanding of managed care operations
Familiarity with guideline development, outcomes management, population health improvement, disease management and cost effectiveness and cost analysis studies
Awareness of physician/provider payment issues, physician practice models and total quality and continuous quality improvement concepts
Medical policy knowledge and skills as related to quality, case and disease management, credentialing activities and utilization management
Excellent communication and collaboration skills for work with network providers and internal employees
Ability to effectively express ideas and gain their acceptance
Ability to implement new and improved approaches to improvement of care and service quality, and to Care Management activities performed by CareOregon
Ability to implement clinical and wellness programs to address the needs of high-risk members
Ability to work effectively as part of a cross-functional team and foster an environment where change is embraced and supported
Ability to deal with issues and problems systemically
Ability to work as an integral part of a team
Ability to plan, set priorities, delegate effectively and utilize time efficiently
Ability to apply innovative and creative approaches to improve health care delivery
Skills in quality management techniques to apply in a large, organized managed care setting
Commitment to improving access and quality of care to the underserved and uninsured
Appreciation of cultural diversity and the needs of serving a diverse patient population
High degree of diplomacy, credibility and persuasiveness to consistently cultivate effective working relationships
An organized, disciplined, hands-on and process-oriented leader
Persistent, assertive, data driven and focused
Proactive and action oriented; drives performance
High degree of initiative and motivation along with the ability to effectively support and collaborate with others to achieve business objectives
Ability to work effectively with diverse individuals and groups
Ability to learn, focus, understand, and evaluate information and determine appropriate actions
Ability to accept direction and feedback, as well as tolerate and manage stress
Ability to see, read, and perform repetitive finger and wrist movement for at least 6 hours/day
Ability to hear and speak clearly for at least 3-6 hours/day

Nice To Haves

Minimum 4 years’ experience in a supervisory position
Benefit/utilization management experience
Leadership experience, preferably to include managed care, quality assurance, utilization review and case management experience

Responsibilities

With the Senior Medical Director, develop, implement and manage clinical and wellness programs to address the needs members.
Implement, direct and oversee utilization, case, disease, and/or quality management programs.
Develop and implement programs for educating participating physicians regarding quality management and utilization management issues.
Represent the health plan in applicable activities including medical and other professional organizations.
Participate in activities that enhance CareOregon’s image within the community.
Serve as a representative and medical spokesperson for the plan in support of Coordinated Care Organizations (CCOs), contract negotiations and other provider expansion activities.
Provide leadership necessary to maintain a motivated, productive and competent team through open communication and delegation of responsibilities and authority.
Provide medical support for Care Management/Care Coordination activities.
Provide medical director oversight, benefit determinations and appeals for medical and pharmacy as assigned by Senior Medical Director.
May integrate with CCO/Line of Business (LOB) Medical Directors to develop, implement, direct, and oversee programs that provide clinical strategy and interventions to CCO/LOB clinical systems.
Support and implement programs for educating network providers regarding best clinical practice using of population/panel management and performance data on clinical quality and utilization.

Benefits

medical, dental, vision, life, AD&D, and disability insurance
health savings account
flexible spending account(s)
lifestyle spending account
employee assistance program
wellness program
discounts
multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings, etc.)
strong retirement plan with employer contributions
PTO
Paid State Sick Time
paid holidays
volunteer time
jury duty
bereavement leave