What are the responsibilities and job description for the Medical Director - Inpatient position at SCAN Health Plan?
About SCAN
SCAN Group is a not-for-profit organization dedicated to tackling the most pressing issues facing older adults in the United States. SCAN Group is the sole corporate member of SCAN Health Plan, one of the nation’s leading not-for-profit Medicare Advantage plans, serving more than 277,000 members in California, Arizona, Nevada, Texas and New Mexico. SCAN has been a mission-driven organization dedicated to keeping seniors healthy and independent for more than 45 years and is known throughout the healthcare industry and nationally as a leading expert in senior healthcare. SCAN employees are a group of talented, passionate professionals who are committed to supporting older adults on their aging journey, while also innovating healthcare for seniors everywhere. Employees are provided in-depth training and access to state-of-the-art tools necessary to do their jobs, as well as development and growth opportunities. SCAN takes great pride in recognizing our team members as experts in their fields and rewarding them for their efforts. If you are interested in becoming part of an organization that is innovating senior healthcare visit www.thescangroup.org, www.scanhealthplan.com, or follow us on LinkedIn, Facebook, and Twitter.
The Job
With a focus on delivering comprehensive, high quality person-centered care across the health care continuum, the Inpatient Medical Director will work closely with SCAN healthcare leadership to provide operational expertise and medical decision support for the day-to-day activities in the areas of Utilization Management, Appeals and Grievances, Medical Claims and Medical Policy with the goal to promote strategies and policies that enhance the delivery of the quadruple aim.
This position is remote with a requirement to be onsite at least once a month and will require travel to meet with providers in different states. This corporate position supports SCAN Health Plan clinical operations in all geographies of operation and serves as the first point of contact for SCAN’s internal clinical teams pertaining to utilization management and other quality programs.
You Will
- Provide medical guidance and interpretation for utilization management operations (prior authorization, concurrent and retrospective review and claims payments).
- Participate in IDT rounds with the focus on the quality of care, utilization management and transition of care.
- Participate in peer-to-peer discussions with provider partners to address healthcare utilization, grievances, and appeals, aiming to enhance the quality of care and alleviate challenges within the healthcare continuum for our members.
- Provide medical expertise to the medical policy team for questions related to daily operations in accordance to Medicare and SCAN guidelines including recommendations for process modifications to improve efficiency and effectiveness.
- Provide clinical review for corporate activities like grievance and appeals.
- Streamline corporate activities review escalation process to MD level when appropriate to improve efficiency in accordance with Medicare, State and SCAN guidelines.
- Provide medical expertise to the medical management team overseeing out of area members to achieve the best outcomes for quality of care and efficiency.
- Participate in the development of evidence-based case management and clinical guidelines for comprehensive healthcare programs such as disease management, complex care management, etc.
- Review and represent SCAN in Administrative Law Judge appeal cases and in CMS & DHCS audits.
- Support effective implementation of performance improvement initiatives with a focus on 5-STAR quality improvement for provider partners. Provide leadership and participate in key clinical committees like P & T, Credentialing, Peer review, and UM. Review quality of care cases and provide recommendations to Credentialing and Peer Review committees. Review provider and facility claims including complex, controversial, and / or unusual or new services to determine medical necessity and appropriate payment. Contribute to team effort by identifying and achieving goals as needed.
All other duties as assigned.
Your Qualifications
What's in it for you?
We're always looking for talented people to join our team! Qualified applicants are encouraged to apply now!
At SCAN we believe that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more.
SCAN is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.
J-18808-Ljbffr
Salary : $213,100 - $341,000
