- Medical Management
- Support strategies and interventions to improve quality outcomes, medical expense trends, and STARS ratings
- Health Care Services Management
- Conduct prior authorization and utilization management activities including adverse determinations.
- Collaborate with consultant physicians as necessary to review selected authorization requests or appeals of adverse determinations.
- Support processes relating to performance and audit of vendors or provider organizations delegated for UM.
- Lead review and submission of clinical practice guidelines, utilization and concurrent review criteria, and other similar guidelines to Medical Policy or applicable committees.
- Participate in Plan committees such as Medical Policy, Credentialing, Quality Improvement, Peer Review and others as assigned.
- Collaborate with medical directors and other clinical leaders from across the contracted network including CHS affiliates as on assigned projects .
- Support care innovations across the enterprise
- Models of Care
- STARS and clinical quality
- Member and provider satisfaction
- Provider network accessibility, availability and qualifications]
- Grievance and Appeals
- Support the development and implementation of the Models of Care across the health plan, the CHS Family of Companies and network of providers.
- Plan Pharmacy Operations
- Participate in various pharmacy related meetings or activities as assigned.
- Support processes related to pharmacy appeals process including appeals of adverse determinations.
- Regulatory and Compliance
- Assure consistent, high quality execution on HIPAA, Privacy, Program Integrity and Fraud, Waste and Abuse protections and activities
- Complete annual Plan compliance training, IRR, and other compliance-related activities.
- Assure adherence to documentation and requirements as set forth in the Model of Care for each MA SNP plan
- Assure adherence to regulatory requirements regarding Quality Committees including Quality Improvement, Credentialing, Medical Policy, Peer Review, Quality of Care committees and related activities
- Growth and Census Support
- Physician Recruitment: Medical Directors, Specialty Physician Program Directors, Attending Physicians
- Attain and enhance physician and hospital relationships to increase referrals
- Participate in data reviews, sharing and initiatives to improve member outcomes
- Liaison to providers when necessary to solicit participation in the Plan provider network, committees or to address QOC or other issues.
- Serve as ambassador to other enterpriseMedical Directors and clinical leaders
- Requires a degree in medicine from an accredited school, Board Certification, and is licensed to practice in applicable states in which the Plan operates.
- Requires at least 15 years of Clinical Experience.
- Requires 3 to 5 years prior experience as a CMO or Associate Medical Director preferably for a Medicare, MMP, or Medicaid plan inclusive of dually eligible enrollees.
- Experience in working in post-acute facilities, assisted living facilities, home and community-based service settings preferred.
- Geriatric training and experience preferred but not required.
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Associate Medical Director - Union, United States - CommuniCare Family of Companies
Description
Associate Medical Director
The CommuniCare Family of Companies currently owns/operates more than 85 Nursing and Rehabilitation Centers, Specialty Care Centers and Assisted Living Communities in 7 states. Since 1984, CommuniCare Health Services has provided superior, comprehensive management services for the development and management of adult living communities.
Due to growth, we are seeking an experienced Associate Medical Director.
The position of part-time Associate Medical Director is responsible for supporting the Medicare Advantage Plans clinical and quality activities and operations at the direction of the Chief Medical Officer approximately 25 hours per week. This position reports directly to the Chief Medical Officer, Medicare Advantage Plans.
Job duties & responsibilities may include the following and will be finalized based on the skills and interests of the successful candidate:
