Medical Director

UHS • Reno, NV

14d

About The Position

Prominence Health is a value-based care organization bridging the gap between affiliated health systems and independent providers, building trust and collaboration between the two. Prominence Health creates value for populations and providers to strengthen integrated partnership, advance market opportunities, and improve outcomes for our patients and members. Founded in 1993, Prominence Health started as a health maintenance organization (HMO) and was acquired by a subsidiary of Universal Health Services, Inc. (UHS) in 2014. Prominence Health serves members, physicians, and health systems across Medicare, Medicare Advantage, Accountable Care Organizations, and commercial payer partnerships. Prominence Health is committed to transforming healthcare delivery by improving health outcomes while controlling costs and enhancing the patient experience.
Learn more at: https://prominence-health.com/
Job Summary:
Reporting to the Chief Medical Officer of Prominence Health Plan (PHP), the Medical Director will direct the development of goals and objectives and the activities related to their achievement for the Health Services Department of PHP which include Utilization Management, Care Management, Disease Management, Quality Improvement, Pharmacy Management, Risk Adjustment, and Community Provider Relations. The Medical Director will provide leadership for the above-mentioned departments and may be asked to participate with and lead other multi-disciplinary or cross functional task-oriented groups within PHP and as appropriate other internal and external units.
Staff Medical Directors hold an active, unrestricted, valid, and current licenses to practice medicine in Nevada, Texas, and/or Florida and are board-certified by a specialty board approved by the American Board of Medical Specialties or the Advisory Board of Osteopathic Specialists or a Doctor of Podiatric Medicine. They are qualified to render appeal determinations in addition to initial determinations and non-certifications. Physician reviewers have access to consult with initial clinical reviewers, other medical advisors, licensed doctors, or peer reviewers through several modes of contact.
This individual is qualified, as determined by the medical director or clinical director, to render a clinical opinion or determination about the medical or behavioral health condition, procedures, and treatment under review and are knowledgeable of the issue under review, or of the current, evidence-based clinical guidelines, and novel treatments for the medical or behavioral health condition, disease, treatment, or procedure under review. Have the clinical expertise to manage the medical or behavioral health condition or disease under review. Individuals who conduct appeal peer review possess a license or certification in a health profession that is of the type and scope that permits them to apply their clinical judgement in consideration of an individual member’s clinical needs to render a utilization review determination.
This individual will play a key role in the direction and execution of the PHP success in Nevada, Texas, Florida, and other markets as indicated related to the delivery of medical services in a population management environment. This medical leader will be responsible for strategically developing and enhancing the existing Medical Management Service Department in the areas of medical policy and procedures, utilization management, peer-to-peer clinical review, pharmacy management, quality of care, quality of service, physician enhancement and development, case/disease management, and appropriate documentation and coding. Furthermore, this medical leader will, as necessary, provide the skills and experience necessary in working with the marketing and sales department to assist in new membership growth and as necessary key account retention.
The Medical Director will be expected to work closely with Provider Relations, represent the organization at key community clinical functions, be visible at important regional and national meetings, and visit medical/hospital entities on a regular basis.

Requirements

• Doctorate Degree in Medicine; in addition to a Master's in health care administration or related field (MBA, MMM, MPH or MHA) preferred.
• Board-certified by a specialty board approved by the American Board of Medical Specialties or the Advisory Board of Osteopathic Specialists or a Doctor of Podiatric Medicine.
• Possess a current, valid, active, and unrestricted license or certification in a health profession to practice medicine in a state or territory of the United States, unless expressly permitted by state or federal law or regulation, when conducting the review, and is recognized in the relevant jurisdictions.
• Free of sanctions from MD Medicaid or Medicare.
• If there is a restriction that is allowed by a relevant jurisdiction, according to the medical director or clinical director, it is of the type that does not affect the health professional’s ability to fulfill the roles and responsibilities of a reviewer.
• Qualified as determined by the Chief Medical Officer or clinical director, to render a clinical opinion about the medical condition, procedures, and treatment under review. Possess a license or certification in a health profession that is of the type and scope that permits them to apply their clinical judgement in consideration of an individual member’s clinical needs to render a utilization review determination.
• Possess a license or certification in a health profession that is: For either a Doctor of Medicine or Doctor of Osteopathic Medicine; or is the same license or certification as the ordering practitioner.
• Minimum five years clinical practice and post-graduate experience in direct patient care.
• Familiarity with Managed Care Principles.
• Familiarity with HEDIS and or CAHPS, STARS, HOS, NCQA, URAC.
• Excellent computer skills.
• Strong internal relationship building skills required.
• Strong external relationship skills required with contracted providers.
• Excellent presentation, oral and written communication skills required.
• Able to travel to all PHP markets and represent the Plan.

Nice To Haves

• Previous Associate Medical Director/Medical Director experience preferred.

Responsibilities

• Direct the development of goals and objectives and the activities related to their achievement for the Health Services Department of PHP which include Utilization Management, Care Management, Disease Management, Quality Improvement, Pharmacy Management, Risk Adjustment, and Community Provider Relations.
• Provide leadership for the above-mentioned departments and may be asked to participate with and lead other multi-disciplinary or cross functional task-oriented groups within PHP and as appropriate other internal and external units.
• Render appeal determinations in addition to initial determinations and non-certifications.
• Play a key role in the direction and execution of the PHP success in Nevada, Texas, Florida, and other markets as indicated related to the delivery of medical services in a population management environment.
• Strategically developing and enhancing the existing Medical Management Service Department in the areas of medical policy and procedures, utilization management, peer-to-peer clinical review, pharmacy management, quality of care, quality of service, physician enhancement and development, case/disease management, and appropriate documentation and coding.
• Provide the skills and experience necessary in working with the marketing and sales department to assist in new membership growth and as necessary key account retention.
• Work closely with Provider Relations, represent the organization at key community clinical functions, be visible at important regional and national meetings, and visit medical/hospital entities on a regular basis.

Benefits

• Loan Forgiveness Program
• Challenging and rewarding work environment
• Competitive Compensation & Generous Paid Time Off
• Excellent Medical, Dental, Vision and Prescription Drug Plans
• 401(K) with company match and discounted stock plan
• SoFi Student Loan Refinancing Program
• Career development opportunities within UHS and its 300+ Subsidiaries!
• More information is available on our Benefits Guest Website: benefits.uhsguest.com

What This Job Offers

• Job Type: Full-time
• Career Level: Director
• Education Level: Ph.D. or professional degree
• Number of Employees: 501-1,000 employees