Permanent Internal Medicine: General Job in Baton Rouge, Louisiana

Position Purpose: Assist the VP of Clinical Programs to direct and coordinate the physician component of the utilization management functions for the Medicare Organization Determination team that supports health plan business units. Provides medical leadership for Medicare utilization management activities, Organizational Determinations, and medical review activities pertaining to utilization review, quality assurance, medical review of complex, and controversial or experimental medical services such as transplants utilizing the services of consultants Performs case reviews and appeals for all health plans Facilitates Grand Rounds and case reviews with other clinicians and external treating providers Participates as an active member of the Integrated Care team (ICT) In collaboration with the VP of Clinical Programs, develops clinical programs and approaches targeted to improve health outcomes for complex care and high acuity populations Assists VP of Clinical Programs in planning, establishing goals and policies to improve quality and cost-effectiveness of care and service for members. Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements. Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components. Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care. Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment Qualifications: Knowledge/Experience: Requires a Medical Doctor or Doctor of Osteopathy, board certified preferably in a primary care specialty (Internal Medicine, Med/Peds, Family Practice, Pediatrics or Emergency Medicine). Previous experience within a managed care organization, specifically reviewing for Medicare Organizational Determinations, preferred. Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is preferred. Experience treating or managing care for a culturally diverse population preferred. The candidate must be an actively practicing physician. License/Certifications: Board Certification through American Board Medical Specialties. Current state medical license without restrictions.

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