Associate Medical Director

Network Health is seeking an Associate Medical Director to join our team. This individual will report to the CMO, and work on a team with other leaders in Population Health. The Associate Medical Director is responsible for day-to-day support of Utilization Management, and NCQA processes that require clinical input. This individual will be supportive of Network Health achieving the goals of market expansion, product expansion, and participation in the Healthcare Exchange. This casual physician leader will be responsible for first level decisions related to utilization management, and be a final decision maker when necessary for case management issues. S/he will not have any committee obligations.

Job Responsibilities:

• Provides input and support for the development of the annual medical expense management plan; accountable for the achievement of utilization and cost targets
• Ensures medical compliance with all regulatory and accreditation requirements
• Identifies potentially unnecessary services and care delivery settings and recommends appropriate alternatives
• Supervises all clinical decision making
• Provides timely communication of and ensures adherence to company policies and procedures
• Participates directly in prior authorization review, concurrent and retrospective review processes
• Reviews actual and proposed medical care and service requests and makes coverage decisions in accordance with NH policy, procedure, and benefit plan designs.
• Works collaboratively in the development, implementation, ongoing monitoring, and outcome analysis of the Quality Improvement Program and responds to physicians and other provider inquiries and complaints within the guidelines of the Quality Improvement Program.
• Participates in development and evaluation of clinical programs to identify and manage members for specific case management and or disease management programs.
• Supports the clinical staff in management of members that are at risk, high risk and high cost
• Maintains up to date knowledge of new information and technologies in medicine and their application to the health plan.
• Directly supports NCQA accreditation processes and maximization of HEDIS scores to meet the highest standards.
• Monitors the quality of care/services provided in assigned areas and strives to continuously improve the service provided to customers.

Job Requirements:

• MD or DO
• Management courses or courses in managed care preferred
• Participation in management committees in a practice or hospital setting required
• Experience as a medical director preferred
• Experience and knowledge of managed care principals, utilization management, case management, quality, and population health.