Role: Mid-Atlantic Medical Director Assignment:Senior Segment Location: WAH
Are you a fit? Do you enjoy defining clinical strategy for a major market area? Do you have a desire to be in a position where you can ‘provide guidance to our members related to their health care needs?
In this role you will be responsible for covering the Mid-Atlantic Region (VA, DE, MD, NC). Travel would be approximately 15% of the time.
You will collaborate with other health care givers in reviewing actual and proposed medical care and services against established CMS, DOI, Humana and other nationally recognized and accepted guidelines. * Provide physician review services for utilization management, case management, quality management, and conduct peer to peer reviews
Develop, maintain and assure compliance with physician review policies and procedures (including timeliness) for utilization management and support case management.
Support collaborative relationships with physicians, large provider groups, hospitals, other facilities and ancillary providers.
Identify potentially unnecessary services and care delivery settings, and recommend alternatives if appropriate by analyzing clinical protocols.
Examine clinical programs information to identify members for specific case management and/or disease management activities or interventions by utilizing established screening criteria.
Conduct admission review, post-discharge and discharge planning with clinical staff and peers
Onsite rounding with clinical staff to support utilization and case management Key Competencies
Leveraging Technology: You are technological savvy and know how to appropriately share and use your knowledge to improve business results.
Problem Solving: You are a problem solver with the ability to encourage others in collaborative problem solving. Acting as both a broker and consultant regarding resources, you engage others in problem solving without taking over.
Is Accountable: You meet clearly stated expectations and take responsibility for achieving results.
Clinical Knowledge: You understand clinical program design, implementation, management/monitoring to support choice in consumer medical care. Understands the medical utilization implications of such programs
Communication: You actively listen to others to understand their perspective and ensure continuous understanding regardless of communication channel or audience.
Role Essentials * A current and unrestricted license in at least one jurisdiction and willing to obtain license, as required, for various states in region of assignment
MD or DO degree
Five years clinical experience
Excellent communication skills Role Desirables
Health Plan Experience
Prior experience as Associate Medical Director (or equivalent) or physician reviewer in a Managed Care Plan
Previous Medicare/Medicaid experience
Previous experience leading teams focusing on utilization management, discharge planning and/or home health or rehab
MD License in VA is preferred but not mandatory
Title: Reviewing Medical Director- Mid-Atlantic - WAH
Location: Virginia-Glen Allen
Other Locations: US-Virginia-Richmond, US-KY-Louisville, US-Delaware, US-Virginia, US-North Carolina, US, US-Maryland
Requisition ID: 179206