Medical Manager Jobs in Romeoville, IL (NOW HIRING)

COMPANY OVERVIEW

Zing Health is a tech-enabled insurance company making Medicare Advantage the best it can be for those 65-and-over. Zing Health has a community-based approach that recognizes the importance of the social determinants of health in keeping individuals and communities healthy. Zing Health aims to return the physician and the member to the center of the health care equation. Members receive individualized assistance to make their transition to Zing Health as easy as possible. Zing Health offers members the ability to personalize their plans, access to facilities designed to help them better meet their healthcare needs and a dedicated care team. For more information on Zing Health, visit www.myzinghealth.com.

SUMMARY DESCRIPTION:

Under the direction of the Chief Medical Officer, the Medical Director provides medical oversight and expertise in the clinical appropriateness and medical necessity of healthcare services provided to Plan members, targeting improvements in efficiency and satisfaction for patients and providers, as well as meeting or exceeding productivity standards. Educates and interacts with network and group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management. Facilitates conformance to Medicare, NCQA and other regulatory requirements. Reviews referred quality of care issues, focused reviews and recommends corrective actions where appropriate. Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. Attends or chairs committees as required such as Credentialing, P&T and others as directed by the Chief Medical Officer.

Evaluates authorization requests in support of nurse reviewers; reviews cases requiring concurrent review and manages the denial process utilizing CMS clinical policies, InterQual, Milliman or other identified Evidence based Medical Policies. Monitors service delivery to our members through the continuum from outpatient services, acute and sub-acute hospital care, skilled nursing facilities to home care to ensure quality, cost-efficiency, and continuity of care. Ensures medical decisions are rendered by qualified medical personnel, not influenced by fiscal or administrative management considerations, and that the care provided meets the standards for acceptable medical care. Ensures that medical protocols and rules of conduct for plan medical personnel are followed. Monitors practitioner practice patterns and recommends corrective actions if needed.

As a member of the Health Services Management team, the Medical Director is responsible for assisting in the development, implementation and review of clinical protocols, performance objectives, productivity benchmarks. Also, the position serves as coach/mentor/trainer to staff clinicians and other staff, giving guidance on best practices, reviewing the delivery of medical services, and identifying operational issues which may impact Member outcomes or staff performance. The Medical Director will assist in examining clinical reporting, predictive analytics, and guidelines to identify members for specific case management and/or disease management interventions by utilizing established screening criteria.  They will conduct admission review, post-discharge, and discharge planning with the health plan clinical staff.  The Medical Director will be a key participant in integrated case management rounds and actively seek additional resources or expertise as needed to assist the member to achieve their best personal health care goals.

Able to utilizes IT and data analysis tools to report on, monitor outcomes, and make suggestions to improve Utilization Management processes and outcomes. Actively participates in regulatory, professional and community activities.

Experience demonstrating strong management and communication skills, consensus building and collaborative ability, and financial acumen.

ESSENTIAL FUNCTIONS: 

• Participates as member of the Health Services management team to develop and implement clinical programs to improve member outcomes.
• Utilization Review
• Case Management Rounds
• Integrated Care Rounds
• Active Participation with training
• Maintain documentation compliant with Health Plan and CMS policies and procedures
• Meet or exceed all Plan Turnaround times for assigned tasks
• Perform other related duties and/or projects as assigned by the CMO
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QUALIFICATIONS AND REQUIREMENTS:

JOB REQUIREMENTS:

Required Qualifications

Education/Experience:

• Board Certified MD with an active and unrestricted Medical license in the United States
• Minimum 5 years of experience in leading teams and working with colleagues to identify and achieve structured goals.
• Minimum 10 years of established clinical experience and current clinical knowledge.
• 2+ years HMO/Managed Care experience preferred
• Possess data analysis and interpretation skills with prior experience working with teams focusing on quality management, utilization management, discharge planning and/or case management.
• Proven competency with Microsoft Office, Word, PowerPoint, Excel, Outlook

Preferred Qualifications

• Minimum 5 years' experience in the managed care industry including Medicare, Medicare Advantage including experience in Utilization/Quality Program management. HMO/Managed Care experience.
• Knowledge of applicable state, federal and third-party regulations
• Experience in Peer Review, medical policy/procedure development, provider contracting experience.
• Experience with NCQA, HEDIS, Medicaid, Medicare and Pharmacy benefit management, Group/IPA practice, capitation, HMO regulations, managed healthcare systems, quality improvement, medical utilization management, risk management, risk adjustment, disease management, medical coding and evidence-based guidelines.