Medical Director Physical Health

Primary Purpose of Position:  

The Medical Director of Physical Health serves as a senior clinical consultant to the Chief Medical Officer in ensuring proper provision of covered services to members and recipients and ensuring an integrated, whole-person approach to the behavioral and physical health of members and recipients with behavioral health, I/DD and TBI needs. The Medical Director collaborates with the Deputy Chief Medical Director-Physical Health in developing and implementing clinical practice standards, clinical policies and procedures, population health and care management protocols, utilization management protocols, pharmacy processes, and quality management oversight. 

Role and Responsibilities:  

•    Supervises specialty needs staffings, huddles, rounds, and other case escalations from care management staff

•    Serves as a clinical supervisor and resource for nursing staff throughout the organization

•    Provides clinical consultation for member appeals

•    Provides clinical consultation including response for crisis calls and care coordination team

•    Offers supervision and training relevant to medical management of members

•    Helps develop key clinical indicators including process and outcome measures

•    Offers guidance and training of targeted clinical care goals such as disease prevention and management of chronic illness

•    Provides on-call coverage for clinical functions in the absence of the CMO

•    Communicates regularly with the CMO regarding clinical concerns and recommendations

•    Communicates with physicians who provide direct care for members where complex factors require physician review and consultations to improve the capacity of the Network to create sustainable, positive outcomes

Quality Management and Pharmacy Operations clinical support and supervision:

•    Provides clinical consultation for grievances, grievance appeals and the provider investigations team

•    Collaborates with CMO and DCMD in analyzing data and developing interventions to improve member and community outcomes

•    Provides support for the Clinical Quality team in developing review tools and technical assistance for providers

•    Supports Pharmacy staff in all areas where physician consult is needed

•    Contact prescribers to support utilization of best practices in medication management and diagnostic testing

Utilization Management:

•    Provides clinical consultation for Utilization Management in authorization decisions

•    Provides Initial Peer Reviews and Reconsideration and Appeal Reviews as appropriate

•    Provides clinical consultation to UM Clinicians, and clinical supervision focusing on medical necessity, reasons for continued inpatient services, state requirements, and appropriate medical practice

•    Provides clinical training for UM staff

•    Supports development & review of clinical best practices, decision tools and clinical practice guidelines

•    Conducts analyses to identify service trends and patterns indicating medically unnecessary care

Community Collaboration:

•    Meets with Regional and State Medical Leadership as directed by the CMO

•    Provides consultation to providers and other community-based clinicians, including general practitioners and specialty providers. Consults with and acts as a liaison with area facilities, physicians, and agencies as requested

•    Participates in Community Clinical Training Events

•    Other duties as assigned

Knowledge, Skills and Abilities: 

•    Broad knowledge of mental health disorders, developmental disabilities, traumatic brain injury and substance use disorders, and of appropriate interventions for those disorders

•    Knowledge about consumers of different age and cultural groups

•    Skilled at providing consultation to other clinical staff, and must interact collaboratively and respectfully with Partners staff, contracted providers, and other external stakeholders

•    Ability to interact professionally with providers, consumers, and stakeholders that may sometimes be upset and exhibit hostility toward Partners and its staff

•    Ability to quickly analyze the critical elements in given situations and provide clear and concise guidance regarding medically necessary and appropriate services

Education/Experience Required:  Minimum of 5 years of experience in a clinical health setting providing medical services, and 2 years of managed care experience. Graduate of an accredited university or medical school with a doctoral degree in medicine. Completed a residency training program in a primary care specialty, including family medicine, or internal medicine. Clinical experience with child/adolescent and adult populations required. Must reside in North Carolina. 

Education/Experience Preferred:  N/A

Licensure/Certification Requirements:   Unrestricted NC Medical license; Must be a primary care physician fully licensed to practice in NC and in good standing.