Medical Director

Summary / Objective :

Function as an integral part of the HealthCare Management team responsible for Utilization Management, Care Management, and Pharmacy Services programs. Represent HealthCare Management in interdepartmental activities and represent Health Partners in the hospital / health system and provider communities and regulatory and governmental activities. Apply clinical expertise and experience as a provider to promote the proper delivery of medically necessary services to the population served.Perform utilization, pharmacy, and quality reviews.

Essential Functions :

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Perform utilization review for requests for services including but not limited to inpatient, outpatient, pharmacy and dental. This will include peer-to-peer discussions with providers.
• Serve on and support the functions of committees including but not limited to the Utilization Management Committee and Pharmacy & Therapeutics Committee.
• Advise the HealthCare Senior Management team regarding the utilization of health care services and interventions to promote the effective delivery of medically necessary services.
• Participate and / or lead rounds including but not limited to disease management, care management or admissions.
• Provide support for Plan accreditation processes (NCQA), Utilization, Quality and Disease Management programs.
• Support ongoing activities in OB, pediatric, adolescent, adult preventative, and geriatric care.
• Develop and or revise practice guidelines for acute and chronic care.
• Develop and implement policies and procedures required to promote effective utilization management and achieve established targets.
• Collaborate with HealthCare Economics and Finance to continuously improve the collection and use of data describing resource utilization and outcomes.
• Represent HealthCare Management internally and externally at the direction of the VP Chief Medical Officer.
• Develop and implement work plans to optimize appropriate utilization and quality targets as directed by the VP Chief Medical Officer.
• Perform other job duties as assigned.

Required Education and Experience :

Skills / Abilities :