Highmark Health Medical Director Position in Wilmington, Delaware
This job provides clinical support to the Medical Management & Policy team to ensure that utilization management activities are performed in accordance with the highest and most current clinical standards. Responsible to review cases and evaluate the medical necessity and appropriateness of the requested treatment of service. Responsible for compliance to NCQA, URAC, CMS, DOH, and DOL regulations. Responsible for appropriate application of Medical Policy and criteria sets. The incumbent provides clinical consultation to the Care Management and Health Coach staff to support the various utilization management and health coach activities.
Serve as a resource for information and consultation on the issues related to utilization management and clinical services.
Retain involvement in all aspects of the medical management process involving medical necessity and appropriateness determinations.
Perform initial determinations, appeals, grievances, peer to peer, pharmacy and other reviews, as assigned
Participate in protocol and guidelines development to ensure consistency in the review process.
Ensure that all aspects of the medical management process are consistent with community standards of care.
Compose clear and concise clinical rationales for member and provider determination notifications.
Assist in the analysis of clinical data elements.
Present data analysis to a wide range of audiences.
Assure high performance standards by meeting targets set by management.
Implement action plans designed to achieve and enhance compliance to accreditation standards in accordance with NCQA, URAC, CMS, DOH, and DOL regulations.
Support Care and Case managers by providing consultation and staff education via clinical presentations and case management conferences.
Interact effectively with members, practitioners/providers, colleague and care and case managers.
Identify, develop and implement projects that align with the company’s strategic goals.
Provide leadership, direction and drive projects.
Manage multiple projects and effectively communicate relevant project information to leadership.
Deliver engaging, informative, well organized presentations.
Resolve and/or escalate issues in a timely manner.
Work with existing or potential vendors.
Drive vendor direction and change as needed.
Work with external providers and facilities on programs to ensure appropriate utilization of health care resources.
Conduct problem solving the scope and frequency of these opportunities is diverse, frequently involving coordination with internal and external customers. The Associate Medical Director has a significant degree of independence in handling day to day operations.
Other duties as assigned or requested.
MD or DO with an unrestricted PA, WV, DE medical license
Board certified in an American Board of Medical Specialties or Bureau of Osteopathic Specialists recognized specialty
Must be credentialed in a Highmark network
Four to eight years’ experience required in active clinical practice.
Graduate degree such as an MBA or MPH
Excellent written and verbal communication skills
Ability to interact with all levels of the organization
Ability to interact with external customers and providers
Ability to analyze data, measure outcomes and develop action plans
Highly effective interpersonal skills
Ability to intervene in crisis situations and multi-task
Computer and software knowledge and skills
SCOPE OF RESPONSIBILITY
Does this role supervise/manage other employees?
Is Travel Required?
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity