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Medical Director

Company: Cameron Craig Group
Location: Hempstead
Posted on: November 14, 2021

Job Description:

The Medical Director will be responsible for managing medical costs and assuring appropriate and optimized health care delivery for members. They will be responsible for leading the organization's efforts to achieve excellence in healthcare cost management, quality, member experience, and improved population and member outcomes. They will serve as a clinical leader for teams dedicated to concurrent review, prior authorization, case management and strategic program development and implementation.
-- Ensure members receive safe, effective, equitable, efficient, timely and patient-centered health care services within their health plan benefits.
-- Carry out medical policies consistent with NCQA and other regulatory bodies.
-- Support pre-admission review, utilization management, concurrent and retrospective review process and case management. Areas of responsibility may include Medical, Behavioral, Pharmaceutical, Dental, Chiropractic and Vision reviews.
-- Work collaboratively as a clinical resource to other plan functions that interface with medical management such as provider relations, provider services, claims management, Business Intelligence, etc.
-- Review appeals of medical and pharmacy denials against established clinical guidelines and make approval and denial determinations in accordance with evidence-based standards, organizational policies and procedures, and regulatory requirements.
-- Participate and/or chair clinical committees and work groups as assigned.
-- Review medical care, medical service, and pharmacy requests against established clinical guidelines and make approval and denial determinations in accordance with evidence-based standards, organizational policies and procedures, and regulatory requirements.
-- Identify potentially unnecessary services and care delivery settings, and recommend alternatives, as appropriate.
-- Provide periodic written and verbal reports and updates as required in the utilization Management, Case Management and Quality Management Program descriptions.
-- Identify opportunities for corrective action plans to address issues and improve organizational performance.
-- Collaborate with Provider Networks, Quality and Medical Management teams in creating and maintaining programs that incentivize providers to achieve selected utilization/cost and quality outcomes.
-- Perform and oversee in-service staff training and education of professional staff.
-- Provide professional leadership and direction in the utilization/cost management (UM) and clinical quality improvement (QI) of THE ORGANIZATION, as measured by benchmarked UM and QI goals.
-- Assure conformance with legal and regulatory requirements; support NCQA qualification activities, including site visits and response to accrediting and regulatory agency feedback.
-- Participate in risk management, claims administration, pharmacy utilization management, catastrophic case review, outreach programs, HEDIS reporting, credentialing, provider orientation and profiling, etc.
-- Conduct quality improvement and outcomes studies as directed by the state and federal regulatory agencies, and internal operating committees
-- Promote wellness and ensure programs of prevention, education and outreach to members and providers consistent with the company's Mission, Vision and Values.
-- Monitor member and provider satisfaction survey results and implement changes as needed to increase satisfaction and assure that satisfactory relationships are maintained between network and plan participants.
-- May be asked to chair various THE ORGANIZATION committees, such as UM, CM, Peer Review and Credentialing.
-- Support the grievance process ensuring a fair outcome for all members.
-- Participate in the retrospective review and analysis of THE ORGANIZATION performance from summary data of paid claims, encounters, authorization logs, compliant and grievance logs, and other sources.
-- Contribute to the development of strategic planning for existing and expanding business; recommend changes in program content in concurrence with changing markets and technologies.
-- Participate in key marketing activities and presentations, as necessary, to assist the marketing effort.
Skills, Knowledge, Abilities:
-- Up-to-date knowledge of new information and technologies in medicine, and their application to appropriate clinical management approaches, as well as computer applications, including productivity tools and Care Management Platforms.
-- Able to manage difficult peer situations arising from medical care review.
-- Knowledge of regulatory and accreditation agencies and requirements
-- Knowledge of medical, quality improvement and UM practices in a managed care environment.
-- Able to manage multiple priorities and deadlines in an expedient and decisive manner.
-- Appreciation of cultural diversity and sensitivity towards target population.
-- Must possess excellent communications skills to interface with providers, staff, and management.
-- Must be available during normal working hours to make coverage decisions. Additional after-hours availability may be required to review emergently or urgently needed services.

  • MD or DO Degree
  • Board Certification preferred
  • NY State License to Practice Medicine

Keywords: Cameron Craig Group, Hempstead , Medical Director, Executive , Hempstead, New York

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