What are the responsibilities and job description for the REMOTE - Medical Director - Health Plan position at Martins Point Health Care?
Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.
Position Summary
The Health Plan Medical Director provides leadership for the clinical care systems that improve the health of our health plan population under the guidance of the Institute for Health Improvement Triple Aim.
The Medical Director brings expertise to and executes on all aspects of the health plan's medical policy, clinical utilization management programs and clinical benefit determinations. This role works closely with health plan leadership to ensure effective development, deployment and measurement of network activities, medical cost management initiatives, and clinical quality improvement programs to support the health of our members / patients.
Job Description
Key Outcomes :
- Participates in clinical aspects of utilization management decision-making, including the establishment of quality standards and performance audits for clinical staff to ensure consistent and accurate decisions
- Supports the selection, development and maintenance of medical policies and clinical protocols that supports utilization management, care management and chronic care management operations
- Contracts and coordinates the services of independent review organizations and individual physicians to satisfy peer reviews for utilization management and appeals decisions
- Collaborates with leadership team on the effective medical cost and utilization performance of the health plan and assists with the development and deployment of strategies for effective medical cost and quality of care management. Includes developing physician performance measurement strategies
- Partners with community providers and the medical leadership of network groups to create support for Martin's Point utilization and population health initiatives
- Provides clinical input and guidance for Health Plan Quality Committees (e.g., credentialing, Physician Advisory Group, and delegation oversight)
- Ensures all clinical programs comply with government program regulations and NCQA accreditation requirements. This includes review of the Health Plan's Annual Quality Management Plan.
- Provides clinical expertise to support product and benefit development efforts
- Manages the clinical aspects of member and provider appeal processing and decision-making
Education / Experience
Required License(s) and / or Certification(s) :
Skills / Knowledge / Competencies (Behaviors) :
We are an equal opportunity / affirmative action employer.
Do you have a question about careers at Martin's Point Health Care? Contact us at : jobinquiries@martinspoint.org
