- Make recommendations on the application of medical necessity criteria for level of care and service eligibility regarding type, amount, and duration of service
- Assist with developing the process to assess and document medical necessity
- Review the approval and denial of care utilizing appropriate medical necessity guidelines
- Assist in functions and collaboration with department including, Utilization Management (UM), Quality Management (QM), Care Management (CM), Peer reviews, and Appeals
- Collaborates with physicians, psychologists, pharmacists, social workers, psychiatric nurses, or other professionals to discuss coordination and overall care of member
- Provides consultation as well as training and education to staff and community partners on relevant topics
- May train and mentor peers of the Medical Management team and PH- medical director new hires
- Work with Human Resources and Medical Team to attract, maintain, and retain a highly qualified and well-trained workforce
- Actively establish and promote a positive, diverse, and inclusive working environment that builds trust with teammates
- Ensure all staff are treated with respect and dignity
- Ensure standards are transparent and applied consistently, impartially, and ethically over time and across all staff members
- Knowledge of the information and techniques needed for diagnosis and treatment of medical issues, including symptoms, treatment alternatives, drug properties and interactions, and preventive health-care measures
- Knowledge of Managed Care Principles
- Knowledge of recent developments in the field of medicine
- Microsoft Office Skills
- Ability to speak with colleagues about treatment concerns, complex case issues and best practice recommendations
- Utilization Management experience preferred
- Medical, Dental, Vision, Life, Long Term Disability
- Generous retirement savings plan
- Flexible work schedules including hybrid/remote options
- Paid time off including vacation, sick leave, holiday, management leave
- Dress flexibility
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Medical Director-Physical Health - Morrisville, United States - Alliance
Description
The Medical Management Team provides guidance and oversight of clinical services requested including authorization of services, operations, and overall clinical direction. The team is responsible for maintaining the integrity of the program, including initial and concurrent utilization reviews of services and procedures.The Physical Health Medical Director assists with oversight of the clinical organization and application of service definition criteria and other standards of care for utilization management requests for services, procedures, and level of care.
This position will offer the ability to work primarily remote. The hire may be required to report on-site as needed. Candidates who are resident of North Carolina or willing to relocate are strongly preferred. The individual in this position may be expected to work weekends as the need arise.
Responsibilities & Duties
Assist with the Development of Service Criteria and Other Standards of Care
Education & Experience
Required:
Graduation from an accredited Medical School. M.D./D.O. degree is required. Completion of approved residency training in internal medicine or family medicine. At least four (4) years of postgraduate clinical experience.
Special Requirement:
Current, active, and unrestricted license to practice medicine in North Carolina or meets qualifications to obtain a North Carolina Medical License with Board certification for appropriate field of Medicine (American Board of Family Medicine or American Board of Internal Medicine).
Preferred:
Two (2) or more years of managed care and utilization management experience.
Knowledge, Skills, & Abilities
$192,208.00 to $320,346.00/Annually
Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity.
An excellent fringe benefit package accompanies the salary, which includes:
