- Formulates and recommends policies relating to covered services, quality assessment and provider oversight. Receives, communicates, and interprets policies of the governing body to direct reports assuring dissemination to the appropriate staff.
- Works closely with the Chief Executive Officer in pursuing matters related to interdepartmental coordination within the clinical aspects of the company.
- Serves as the Plan's principal liaison with and represents the Plan in meetings with providers to facilitate collaborative efforts to improve patient care.
- Serves on various committees, task forces and special project teams of the Plan.
- Provides leadership and management to ensure effectiveness of the medical policies by maintaining an ongoing evaluation of the provider communities' quality of care and managed care educational needs.
- Participates in development of job descriptions and duties for clinical staff.
- Participates in interview and hiring process for key clinical staff positions including, but not limited to, all nursing leadership positions and all Medical Directors.
- Participate in annual evaluation process for all clinical staff.
- Approximately 50% of time is devoted to quality related activities.
- Responsible for presentation and interpretation of utilization data both internally and externally.
- Develops and manages medical policies and procedures and ensures compliance with them.
- Advises and assists the networks/physicians in ensuring the effectiveness of programs and meetings.
- Works closely with owner health systems to assure alignment of policies and goals to attain improved quality and increased efficiency.
- Works to develop internal staff by empowerment, training opportunities, and provision of resources to allow all healthcare management staff to function at maximal effectiveness and efficiency.
- Ensures the organization has qualified clinicians (including physicians, licensed nurses) accountable for decisions affecting consumers.
- Remains available for real-time consultation and to be a resource for the nurse reviewer's determinations.
- Renders a determination on medical or drug utilization management cases under appeal.
- Supervises overall staff administration within the clinical departments to assure staffing is appropriate for needs but not excessive.
- Ensures compliance with federal and state laws, federal and state regulations, and the standards of the regulating bodies/certifying organizations.
- Ensures compliance with rules, regulations, and implementation of sanctions where indicated by regulatory or accrediting bodies.
- Due to changes in health care law, the SVP, Chief Medical Officer will also work with the organization and its owners to jointly develop and maintain additional functionality that will be required in a new health care environment to possibly include: case management programs, transition to home programs, patient-centered medical home expertise and consultation, data analysis and reporting, support development of information technology infrastructure, and other items that may enhance the efficiency and quality of the organization.
- Performs other duties as necessary.
- Demonstrated experience and leadership abilities within a health plan organization.
- Well-developed interpersonal skills with the ability to interpret complex information from a variety of sources.
- Demonstrated success in working with health systems while managing cost benefits for the health plan and insurance providers.
- Creative, energetic individual with strong public relations abilities.
- Professional demeanor with a positive attitude and self-motivation.
- Previous discharge planning, care coordination, or case-management experience.
- Prior experience with complex data including management, reporting, visualization, and communication thereof.
- Successful completion of Health Care Sanctions background check.
- Ability to converse and write fluently in English.
- Graduation from accredited medical school.
- Residency trained in their discipline.
- Minimum of five years in post residency clinical practice.
- Current and active unrestricted license to practice medicine in the State of Oklahoma
- Board certified - certification must be maintained.
- Minimum five years' experience in a health plan senior leadership role.
- Additional management training strongly recommended – Masters degree in related discipline preferred (MBA, MHA, MMM, MS-HQSM, etc).
- License if of the type and scope that permits them to apply their clinical judgement in consideration of an individual member's clinical needs to render a utilization review determination.
- For Appeal Peer Review, licensed as either a Doctor of Medicine or Doctor of Osteopathic Medicine.
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SVP, Chief Medical Officer - Tulsa, United States - CommunityCare
Description
JOB SUMMARY:
Physician leader who is responsible for the overall direction and coordination of all clinical affairs including overseeing Medical Management, Pharmacy Services, Behavioral Health, Health Equity, Employee Assistance Program, and Wellness programs. Serves as principal clinical advisor for medical and behavioral operational areas including continuous quality improvement functions related to delivery of care; establishment of policy; and providing input on issues related to delivery of pharmaceutical and ancillary services. Knowledgeable and has clinical expertise of the issues under appeal review including the current evidence based clinical guidelines and the appropriate treatments for the medical or behavioral health conditions, procedures, or diseases under review. Responsible for and actively participates in all clinical committees that include network providers, either serving as chairperson or appointing a representative as chairperson.
KEY RESPONSIBILITIES:
QUALIFICATIONS:
EDUCATION/EXPERIENCE:
SVP, Chief Medical Officer professionals in Tulsa
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Dr Felix REGELE
Cover Letter/Statement
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James Wentz
Licensed Practical Nurse