Medical Management - Medical Director 145-7004

JOB SUMMARY: The Medical Director will exhibit strong expertise in utilization management and health plan leadership for our provider sponsored organization. They will have a proven track record working within a health plan environment, with a deep understanding of clinical operations, healthcare utilization, and strategies for controlling healthcare costs while maintaining high-quality care. This key role within our Clinical Operations team is pivotal in optimizing the efficiency and effectiveness of our health plan’s utilization management programs, ensuring that medical services are delivered in a cost-effective manner while meeting the clinical needs of our members. KEY RESPONSIBILITIES: Utilization Management: Lead and oversee the health plan's utilization management policies, ensuring that care is appropriately managed across all settings (inpatient, outpatient, ancillary services, etc.). Establish and enforce medical necessity criteria, review processes, and decision-making protocols. Collaborate with providers to enhance care coordination and cost efficiency through peer-to-peer reviews and secondary reviews. Cost Control Strategy: Develop and implement cost-effective strategies for managing the utilization of healthcare services. Utilize data-driven approaches to identify trends and opportunities to improve care delivery while reducing unnecessary costs. Collaborate with other departments to integrate cost containment initiatives across the plan. Clinical Leadership: Provide clinical oversight and direction for the medical management team. Serve as a subject matter expert on clinical best practices, evidence-based guidelines, and cost-effective care delivery. Management of and/or participation in internal company committees as requested. Appeals and Grievances: If not involved with the initial denial determination, renders an appeal determination on medical, behavioral or drug utilization management cases under review. Collaboration and Communication: Work closely with cross-functional teams including the network management, claims, quality improvement, and pharmacy departments to design, implement, and monitor health plan initiatives. Policy and Compliance: Ensure compliance with all relevant federal and state regulations, accreditation standards, and health plan policies. Stay current with industry trends, regulatory changes, and emerging healthcare technologies related to utilization management and cost control. Performance Metrics and Reporting: Develop and track performance metrics related to utilization, cost control, and quality outcomes. Provide regular reports to senior leadership, identifying opportunities for improvement and recommending actionable steps. Member and Provider Education: Educate and support providers on evidence-based guidelines and efficient care delivery practices. Engage with members to promote care management and prevention programs that align with cost-effective health outcomes. Innovation and Continuous Improvement: Promote a culture of continuous improvement within the medical management team. Lead efforts to enhance the efficiency of clinical workflows, reduce administrative burden, and introduce innovative solutions to optimize both clinical care and cost-effectiveness. Other Projects and Responsibilities: Perform other special projects and duties as assigned by the executive staff of CommunityCare Managed Healthcare Plans.   QUALIFICATIONS: Strong analytical and data-driven decision-making skills, with experience using claims data, cost analysis, and reporting tools. Excellent communication, leadership, and interpersonal skills. Knowledge of regulatory and compliance standards within the managed care industry preferred.   EDUCATION/EXPERIENCE: MD or DO, maintain board-certification in an ABMS recognized specialty. Current and active unrestricted license to practice medicine in the State of Oklahoma. Minimum 5 years direct patient care and clinical experience in their specialty. Previous experience as a Medical Director with a health plan, managed care, or health insurance organization. Proven expertise in utilization management, medical necessity reviews, and cost containment strategies. In-depth knowledge of healthcare delivery systems, including inpatient, outpatient, and ancillary care. Experience with clinical guidelines, evidence-based practices, and care management programs. Experience with health plan accreditation processes (NCQA, URAC, etc.) preferred. Familiarity with healthcare technology platforms, such as electronic health records (EHR) and utilization management software preferred.