What are the responsibilities and job description for the Medical Director of Quality and Utilization position at Sunshine State Health Plan?
Join our team at Sunshine State Health Plan as a key leader in medical management. As a Behavioral Medical Director, you will play a critical role in directing and coordinating the medical management, quality improvement, and credentialing functions for our business unit.
The ideal candidate will have a strong background in utilization management, cost containment, and medical quality improvement activities. They should be able to perform medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services.
This position requires effective implementation of performance improvement initiatives for capitated providers. The successful candidate will assist in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members.
We are seeking a medical expert who can provide guidance on approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.
The successful candidate will also assist in the functioning of physician committees, including committee structure, processes, and membership. Conducting regular rounds to assess and coordinate care for high-risk patients is an essential aspect of this role.
We value collaboration and teamwork. As a Behavioral Medical Director, you will work closely with clinical teams, network providers, appeals teams, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals.
This is a unique opportunity to participate in provider network development and new market expansion as appropriate. You will also assist in the development and implementation of physician education with respect to clinical issues and policies.
