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Career Opportunities
Title:
Company:
Location: |
Adult Medical Director
Leading Managed Behavioral Healthcare company
Western US |
Job Description:The Adult Medical Director will provide oversight of a comprehensive medical policy implementation and utilization management services for the adult team. The Medical Director develops and sustains an interface with member forums and facilitates the delivery of appropriate care to adult enrollees. A licensed MD experienced in managed care operations, the Medical Director contributes to the development of the clinical mission, including the development, implementation, and evaluation of clinical/medical adult programs.
As this role involves the largest public sector HMO in the country, visibility will be key, both inside and outside the company. The candidate that assumes this role and truly performs, will certainly be considered for promotion opportunities.
Roles & Responsibilities:Senior Medical Reviewer: Direct the utilization review process and oversee the quality of utilization determinations for adult enrollees
Responsible for the quality of the utilization review determinations.
Develop and implement a utilization management program and action plan
Ensure compliance with clinical goals through regular monitoring of care management center performance
Evaluate the effectiveness of the clinical program and modify programs as need to achieve desired results
Provide medical leadership, oversight, and consultation for the Quality Improvement Program, and Utilization Management Program for adult enrollees
Monitoring effectiveness and compliance with goals, prevention programs, network development and management, quality of care concerns and adverse incidents, medical practice of network or sub-capitated providers, clinical service delivery system.
Coordination with After Hours Team and appeals -panel physicians, oversight of clinical appeals
The Medical Director works collaboratively with QI on the development and implementation of QI activities, UM and QI program descriptions, evaluations, and work plans
Attends or co-chairs the P&T committee meetings
Participates in the development of, implements and interprets medical policy for adult enrollees (including Medical Necessity Criteria, Clinical Practice Guidelines and New Technology Assessments)
Recruit, train, supervise, mentor, oversee, and evaluate the quality of medical staff and physician advisors utilized
Ensure that the site has adequate physician advisor resources
Develop and manage the physician advisor budget
Job Requirements:The ideal candidate will be a dynamic, visionary executive with strategic and operational expertise plus strong presentation and networking skills. The Medical Director will rely on charisma, presence and medical expertise combined with a strong managed care background to succeed in this fast-paced environment. He/ she should be an MD with expertise in managed care.
In addition, a right-fit candidate will possess the following:
- Managed care experience required, as a provider and/ or manager of care
- Post-residency experience of at least 5 years involving substantial direct patient care during this period at multiple levels of care
- Full training in a residency program in the US or Canada that is approved by the ACGME (Accreditation Council for Graduate Medical Education)
- Clinical experience pertinent to the patient population(s) being managed (adults)
- Must have current active license to practice medicine within the US
- Licensed or eligible for licensure within the state of Arizona (must complete licensure within first year of employment)
- Knowledge of current research, recovery/ resiliency principles, medication and psychotherapy
- Familiarity with current research and use of psychopharmacologic & psychotherapeutic modalities of treatment
- Utilization Review experience preferred
- Accreditation experience (NCQA, AAHCC/URAC) preferred
- Graduate of an American or Canadian medical school accredited by the Accreditation Council for Medical Education (ACME) or equivalent training in a foreign medical school with successful completion of the ECFMG (Educational Commission for Foreign Medical Graduates) and FLEX (Federal Licensing Examination) examinations
- Board Certified by the American Board of Psychiatry & Neurology
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