Onsite/Not a Remote Position
Position Purpose: Responsible for the overall management of the medical division including medical management, case management, utilization management and all other division functions.
Responsibilities:
- Identification of utilization patterns to evaluate trends in inpatient and outpatient utilization.
- Identifies and evaluates unusual provider practice patterns.
- Monitors adequacy of benefit/payment components.
- Work collaboratively with quality improvement, member services, medical care management, provider relations and the executive team to improve quality of care and outcomes.
- Participates in the review and assessment of complex and/or unique claims.
- Solicit and evaluate advice of outside medical consultants and physicians with respect to complex or experimental procedures.
- Provides medical expertise with respect to planning and establishing goals and objectives to improve medical care management and outcomes.
- Participates in provider network development and new market expansion as appropriate.
- Participates in the review, assessment and negotiation of provider contracts as needed.
- Interfaces with the provider community regarding medical care management, utilization review and quality improvement issues and concerns.
- Performs other related duties as indicated by the President/CEO and/or the Board of Directors.
Qualifications:
- Medical degree from an accredited University.
- Board eligible or certification in primary care.
- Minimum of 5 years experience in managed care.
- Experience in the development and management of utilization review and quality improvement programs.
- Outstanding oral and written communication skills.
- Excellent leadership skills and the ability to motivate through a proactive management style.
Note: This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s). Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.
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