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This position provides informal leadership for the development and evaluation of clinical care systems that improve the health of our patients and members under the guidance of the Triple Aim.
The Medical Director brings background to and executes on all aspects of the health plan's medical policy, clinical utilization management programs and clinical benefit determinations. Position works closely with leadership to ensure effective development, deployment and measurement of network activities, medical cost initiatives and quality improvement programs in support of the health of our members/patients. The Medical Director supports network provider engagement and NCQA accreditation.
This position develops and deploys clinical policy under the auspices of the Senior Medical Director and Martin's Point Health Care's Chief Medical Officer's clinical vision and works in concert with Plan and Practice to ensure consistency and collaboration for all medical policy, clinical quality, guidelines, and overall medical cost management.
Please note that is either a part-time or full-time position. (24-40 hours/week)
- Participates in clinical aspects of utilization management decision-making, including the establishment of quality standards and performance audits for clinical staff to ensure consistent and accurate decisions
- Directs medical policy determinations including the adoption of external resources as well as internal decision making and documentation; creating and maintaining a database of internal medical policies to supplement external resources.
- Involved in the clinical aspects of member and provider appeal processing and decision-making
- Contracts and coordinate the services of peer-review organizations and individual physicians to satisfy matched-specialty reviews for utilization management and appeals decisions Collaborates with leadership team on the effective medical cost and utilization performance of the health plan and assist with the development and deployment of strategies for effective medical cost and quality of care management
- Assists in the deployment of NCQA accreditation and ongoing compliance including review of the Health Plan's Annual Quality Management Plan.
- Provides clinical input and guidance for Health Plan Quality Committees (e.g. credentialing, delegation oversight)
- Ensures all clinical programs are in compliance with government program regulations and NCQA accreditation requirements.
- Partners with community providers and the medical leadership of network groups to create support for Martin's Point utilization and population health initiatives
- Leads Partners with Medical Director and Health Plan leaders to execute on utilization review and care management interventions and provides input on effective means for implementation and evaluation.
- Supports the development of physician performance measurement strategies in collaboration with a variety of other internal and external stakeholders and may engage network physicians in the process and act as peer contact with network providers delivering physician detailing on performance measures and clinical care gaps for patient populations.
- Supports the selection, development and maintenance of medical policies and clinical protocols that supports utilization management, case management and chronic care management operations
- Provides clinical expertise to support product development efforts
- Medical degree with 10+ years of practice experience required; Board certified
- Active and unrestricted license to practice medicine or surgery in Maine required, NH preferred
- 5+ years of applicable managed care experience with progressively increasing responsibilities in medical director capacities, including utilization management and medical policy development, required
- People leadership experience preferred
- Knowledge of local provider community preferred
- Extensive knowledge and practical understanding of healthcare systems and managed care concepts
- Demonstrated ability to develop medical policy and manage cost of care under the guidance of the Triple Aim
- Demonstrated ability to informally or formally lead change (internally and externally) and produce measurable results within a specified time period
- Demonstrated ability to lead, manage and collaborate with others, even without authority
- Demonstrated ability to educate and promote best practices to physician and clinical care communities
- Knowledge of and a deep commitment to performance-based health plan systems
- Good analytic skills with the ability to identify meaningful trends and targets for improvement.
- Excellent interpersonal skills and the demonstrated ability to establish rapport and working relationships with providers, service vendors, employers, regulatory and community groups.
- Strong communication and presentation skills; ability to tailor message to a variety of audiences.
- Successful utilization of process improvement tools and methods to achieve results
We are an equal opportunity/affirmative action employer.
Do you have a question about careers at Martin's Point Health Care? Contact us at: firstname.lastname@example.org