Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit
Provides medical leadership 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
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
Interfaces with physicians and other providers to facilitate implementation of recommendations to improve utilization and health care quality
Reviews claims involving complex, controversial, or unusual or new services to determine medical necessity and appropriate payment
Develops alliances with the provider community through the development and implementation of the medical management programs

Medical Doctor or Doctor of Osteopathy
Utilization Management experience and knowledge of quality accreditation standards preferred
Actively practices medicine
Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is advantageous
Experience treating or managing care for a culturally diverse population preferred
Board certification in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Association’s Department of Certifying Board Services
Active Certification in Internal or Family Medicine, preferred
Current state license as a MD or DO without restrictions, limitations, or sanctions from government programs

National Medical Director

Key skills