Key Role in Healthcare

We are seeking a clinical professional to join our Medical Management/Health Services team, impacting the lives of 28 million members.

Responsibilities

• Direct and coordinate medical management, quality improvement, and credentialing functions for the business unit under the guidance of the Chief Medical Director.
• Provide medical leadership for utilization management, cost containment, and medical quality improvement activities.
• Perform medical review activities, ensuring timely and quality decision-making on complex, controversial, or experimental medical services.
• Sustain effective implementation of performance improvement initiatives for capitated providers.
• Assist the Chief Medical Director in planning and establishing goals and policies to enhance quality and cost-effectiveness of care and service.
• Offer medical expertise in approved quality improvement and utilization management programs according to regulatory, state, corporate, and accreditation requirements.
• Participate in physician committee operations, including structure, processes, and membership.
• Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes.
• Collaborate effectively with clinical teams, network providers, appeals teams, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals.
• Support provider network development and new market expansion as necessary.
• Assist in developing and implementing physician education regarding clinical issues and policies.
• Identify utilization review studies and evaluate adverse trends in medical service utilization, unusual provider practice patterns, and benefit/payment component adequacy.
• Identify clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice to improve the quality and cost of care.
• Interface with physicians and other providers to facilitate implementation of recommendations that improve utilization and healthcare quality.
• Review claims involving complex, controversial, or unusual or new services to determine medical necessity and appropriate payment.
• Develop alliances with the provider community through medical management program development and implementation.
• Represent the business unit before various publics locally and nationally on medical philosophy, policies, and related matters as needed.

Requirements

• Medical Doctor or Doctor of Osteopathy degree required.
• Utilization Management experience and knowledge of quality accreditation standards preferred.
• Actively practicing medicine.
• Coursework in Health Administration, Health Financing, Insurance, and/or Personnel Management advantageous.
• Board certification in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Association's Department of Certifying Board Services.

Benefits

• Competitive pay.
• Comprehensive benefits package including health insurance, 401K, and stock purchase plans.
• Tuition reimbursement.
• Paid time off plus holidays.
• A flexible approach to work with remote, hybrid, field, or office work schedules.