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 the Chief Medical Director in the functioning of the physician committees.
Conduct regular rounds to assess and coordinate care for high-risk patients.
Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants.
Participates in provider network development and new market expansion as appropriate.
Assists in the development and implementation of physician education with respect to clinical issues and policies.
Identifies utilization review studies and evaluates adverse trends.
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 Health Administration, Health Financing, Insurance, and/or Personnel Management 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.
Current state license as a MD or DO without restrictions, limitations, or sanctions from government programs

National Medical Director

Key skills