What are the responsibilities and job description for the MEDICAL DIRECTOR (SPECIALTY IN FAMILY/INTERNAL MEDICINE) position at The Health Plan of West Virginia, Inc.?
Medical Professional(s) responsible for direction and oversight of healthcare services provided to Plan members to ensure the delivery of cost-effective, quality services. The Medical Director shall be responsible for Medical Direction of all activities of the Quality Management and Utilization Management Programs of The Health Plan. This will be a Dyad relationship with the Directors of Utilization and Quality Management and Pharmacy Management.
Required :
Active physician license without restriction.
Meets all THP credentialing requirements.
Three years managed care experience in HMO setting preferred.
Board certification.
Minimum of five years post graduate clinical experience.
Desired :
Basic computer literacy.
Prior leadership roles while in clinical practice is desirable.
Demonstrated ability to work in unison with other professionals and non-professionals in a respectful and harmonious manner.
Responsibilities :
Provide Physician oversight for activities related to the company's Utilization Management, Disease Management and Quality Management programs ensuring compliance with NCQA, Medicare, Medicaid, and other regulatory entities. Play an active role in preparing for related audits and information requests from such entities.
Establish the highest standards of best medical practices for care provided to members through participation in the development of clinical practice guidelines and selection and procurement of suitable proprietary criteria and clinical pathways.
Provide physician education regarding Health Plan utilization management and quality management protocols and initiatives. Work with individual physicians or physician groups to achieve acceptance and understanding of Health Plan medical appropriateness criteria, practice guidelines and patient care programs.
Carry out specific functions as outlined in the Utilization Management Program including :
a. Play a leadership role in the development and implementation of the Utilization Management Program including assisting in the development of the annual work plan and program evaluation. Serve as chairperson and or member of various utilization management committees as set forth in the Utilization Management Program Description.
b. Review clinical utilization and the delivery of acute care to members on a daily basis. Maintain daily interaction with hospital review, case managers, care managers, disease managers, pharmacy managers, claims managers and other staff.
c. Review all cases where medical appropriateness is questioned and provide overall responsibility for authorization or non-authorization based on medical appropriateness of the health care services requested.
d. Available to communicate telephonically with practitioners in case review matters.
e. Available as needed to provide twenty-four hour coverage for case review matters.
f. Actively participates in the functioning of the plan appeal and grievance procedures.
Carry out specific functions as outlined in the Quality Management Program including :
a. Play leadership role in the development and implementation of the Quality Management Program including assisting in the development of the annual work plan and program evaluation. Serve as chairperson and / or member of various quality management committees as set forth in the Quality Management Program Description including but not limited to the Quality Improvement Committee, the Credentials Committee, the Pharmacy and Therapeutics Committee, the Transplant and Technology Committee, Utilization Management Committee and other related committees.
b. Monitors, evaluates, and validates clinical quality issues and refers them to the appropriate internal staff, committees or institutional regulatory bodies.
c. Collaborates in organizing a continuous quality improvement mechanism for The Health Plan and in identifying specific clinical goals and objectives for focus or priority.
d. Acts as a guide and resource to the Quality Management Program in the collection and analysis of data related to quality studies and surveys. Participates in the qualitative analysis of data to identify barriers and corrective actions as well as re-evaluation after intervention.
Works directly with Network Development staff to develop and coordinate effective provider education / intervention programs including providing input into provider training and education programs, review of provider manuals and direct contact with providers as needed.
Perform other duties and special projects as assigned to accomplish the goals of the organization.
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