The Senior Medical Director is responsible for supervising Medical Directors and Medical Policy development/implementation, providing and supervising prior authorization decisions, clinical appeal decisions, participation in peer-to-peer physician calls, and leading clinical rounds with nursing staff. Responsibilities also include maintaining relationships with self-funded employer groups which may require limited travel to our clients in Washington and other states. In addition, it?s an opportunity to work with the Chief Medical Officer and senior management team in strategic planning. This position provides an excellent opportunity to grow and develop Chief Medical Officer knowledge and skills.
Provide timely Utilization Management, Case Management, and Behavioral Health support: case reviews, appeals, physician calls, clinical rounds, daily operations.
Maintain accountability for Medical programs and associated data collection and reporting requirements.
Provide leadership and accountability for efficient, timely, and evidence-based medical policy development.
Provide clinical oversight and act as liaison to Pharmacy Benefit Services.
Assist with Utilization Management, Case Management, and Behavioral Health Policy and Procedure enhancements, educational rounds, and other activities to maintain Health Utilization Management and Case Management URAC Accreditations.
Provide Medical Director expertise and support for QI projects to meet or exceed URAC standards.
Assist in evaluation of quality of care concerns or complaints.
Support or chair select committees as identified by CMO, including but not limited to: Medical Policy, Payment Policy, Appeals, Credentialing, Healthcare Analytics, Medical Advisory, and ad hoc committees.
Provide marketing support as requested.
Participate in community activities as identified.
Coordinate with VP of Medical Management to ensure adequate support of Medical Management Department.
Coordinate with VP of PPO Ops to ensure adequate support of Credentialing.
Other duties as assigned.
Leadership experience, medical director experience in utilization management in a TPA, and a minimum of ten years of clinical experience. Strong organizational, communication, analytical, management, presentation and negotiation skills. Knowledge of quality, healthcare reform, value-based care, contracting and payor relations, risk management, and clinical innovation.
Current, active, unrestricted license to practice medicine in Washington State and residing in the Puget Sound area.
Current ABMS board certification in a clinical specialty, preferably Family Practice, Internal Medicine, or Emergency Medicine.
Minimum 5 years of clinical practice experience.
Experience as a medical director, preferably in a medium sized TPA, health plan or managed care group.
History of work in Quality, Utilization Management, Case Management, Claims Review, Medical Policy and Implementation, and working with regulatory bodies such as URAC.
6Experience in managing physicians - employed and/or contracted.
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How to Apply
Please submit your resume to firstname.lastname@example.org.
Additional information about our company may be found on our website www.fchn.com