Assist the VP of Clinical Programs to direct and coordinate the physician component of the utilization management functions for the health plan business units.
- Provides medical leadership for utilization management activities 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.
- 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
Education/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) or other specialty familiar with Medicare patients. 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. The candidate must be an actively practicing physician. More than 1 state license is preferred.
License/Certifications: Board Certification through American Board Medical Specialties. Current state medical license without restrictions.