Medical Director - Health Plan - Remote Eligible
Requisition ID: 2024-43056
Category: Physician
Location: Rev Hugh Cooper Admin Center, Albuquerque, NM
Minimum Offer: USD $107.63/Hr.
Maximum Offer for this position is up to: USD $134.53/Hr.
Overview
Presbyterian Healthcare Services exists to improve the health of patients, members, and the communities we serve. We are a locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan, and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1,600 providers and nearly 4,700 nurses.
Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid, and Commercial health plans.
The Medical Director for the Health Plan reports to Presbyterian Health Plan (PHP)'s Senior Medical Director. S/he will be primarily responsible for performing medical necessity determinations in partnership with PHPs Utilization Management and is responsible for ensuring that medical protocols and practice guidelines are followed. This includes utilization management of health care services primarily with the prior authorization staff, participation in formulating complex care coordination, as well as peer-to-peer discussions with community clinicians. The Medical Director will also provide medical oversight, expertise, and leadership to ensure the delivery of cost-effective, quality healthcare services for PHP members.
Open to remote applicants in the United States, except for the following states: Wyoming, North Dakota, and Ohio.
Qualifications
- M.D. or D.O. degree, with board certification.
- Five years clinical practice experience in pediatric and adult medicine after residency training, currently New Mexico licensed to practice without restriction.
- Experience in a managed care setting strongly preferred.
- Experience in the application of evidence-based clinical practice guidelines and resource, utilization, and cost management initiatives.
- Basic computer literacy and skills (i.e., Microsoft Office, electronic medical records systems).
- Requires detailed knowledge of medical management principles, including utilization management, case management, retrospective and concurrent review, and prior authorization, in terms of theories and practices both directly and to serve as the resource or educator to other practitioners.
- Understanding of managed care environment.
- Experience with Medicare, Medicaid, and state programs desirable.
- Familiarity with National Committee for Quality Assurance (NCQA) and with Health Plan Employer Data and Information Set (HEDIS) principles and requirements desirable.
Responsibilities
- Support development and revisions to Medical Policies.
- Assist in initiatives to ensure accessibility of quality, affordable care and coverage for PHP's customers and members.
- Provide clinical leadership and promote best practices across the Presbyterian organization.
- Manage relationships with providers across the state.
- Support population health efforts, including a large population of vulnerable individuals in achieving their best health.
- Play an integral role within a fully integrated healthcare system.
- Break new ground in medical cost management and population health management.
- Support New Mexico in improving the health of its population.
- Provide guidance and support for forward-thinking quality improvement initiatives.
- Other functions as required.
Benefits
We offer more than the standard benefits! Presbyterian employees gain access to a robust wellness program, including free access to our on-site and community-based gyms, nutrition coaching and classes, wellness challenges, and more!
Learn more about our employee benefits: Employee Benefits
As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans.
Presbyterian's story is really the story of the remarkable people who choose to work here. The hard work of our physicians, nurses, employees, board members, and volunteers grew Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system that serves more than 875,000 New Mexicans.
Compensation Disclaimer
The compensation range for this role takes into account a wide range of factors, including but not limited to experience and training, internal equity, and other business and organizational needs.
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