Permanent Administrative Job in Indianapolis, Indiana
Position Purpose: Assist the Chief Medical Director to
direct and coordinate the medical management, quality improvement and
credentialing functions for the business unit.
Provides
medical leadership of all for utilization management, cost containment,
and medical quality improvement activities. Performs medical review
activities pertaining to utilization review, quality assurance, and
medical review of complex, controversial, or experimental medical
services. Supports effective implementation of performance improvement
initiatives for capitated providers.
Assists Chief Medical
Director in planning and 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.
Assists the
Chief Medical Director in the functioning of the physician committees
including committee structure, processes, and membership. Oversees the
activities of physician advisors. Utilizes the services of medical and
pharmacy consultants for reviewing complex cases and medical necessity
appeals. Participates in provider network development and new market
expansion as appropriate. Assists in the development and implementation
of physician education with respect to clinical issues and policies.
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.
Interfaces with physicians and other providers in order to facilitate
implementation of recommendations to providers that would improve
utilization and health care quality. Reviews claims involving complex,
controversial, or unusual or new services in order to determine medical
necessity and appropriate payment.
Develops alliances with
the provider community through the development and implementation of the
medical management programs. As needed, may represent the business unit
before various publics both locally and nationally on medical
philosophy, policies, and related issues. Represents the business unit
at appropriate state committees and other ad hoc committees
Consults on MCO clinical policy related to Substance Use Disorders and
the cases of individual members for the MCM program on a routine basis.
Education/Experience: Medical Doctor or Doctor of
Osteopathy, board certified preferable in a primary care specialty
(Internal Medicine, Family Practice, Pediatrics or Emergency Medicine).
The candidate must be an actively practicing physician. Previous
experience within a managed care organization is 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.