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Senior Medical Director, Options - Wilmington, DE, United States - Highmark Health
Description
This job leads a physician team and ensures that utilization management responsibilities are performed in accordance with the highest and most current clinical standards.
The incumbent oversees a team of Medical Directors who are responsible for reviewing escalated cases electronically and using Medical Policy criteria sets, evaluating the medical necessity and appropriateness of the requested treatment of service.
The physician team must ensure compliance to NCQA, URAC, CMS, DOH, and DOL regulations at all times, and the Senior Medical Director will be responsible for ensuring that those measures are met.
They will advise the multidisciplinary team on cases, particularly high-risk cases, through the team structure. Additionally, the physicians may be assigned special projects to help support and improve the care of our members.As the leader of these physicians, the Senior Medical Director will manage performance accordingly, delegate projects, and determine which team members will participate in which multidisciplinary teams.
Also, as a physician leader, the incumbent consults other departments across the organization and with key provider networks as needed.
They may serve on committees or project teams as a subject matter expert, depending on specialty and prior experience.Perform management responsibilities including, but not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity.
Plan, organize, staff, direct and control the day-to-day operations of the department; develop and implement policies and programs as necessary; At times, own/lead projects related to process improvement, system enhancements, and/or improvement of utilization management, quality of care and/or member services.
Collaborate with providers to enhance care and population health management services.Identify industry benchmarks and analyze and synthesize data and research to identify best practices relevant to clinical operations. Develop and lead a culture of continuous process improvement and care cost focus.
Monitor and remediate regulatory compliance standards and develop tools and processes geared toward inter-rater reliability to promote consistent and appropriate utilization management decisions.
Doctor of Medicine or Doctor of Osteopathic MedicineMaster's Degree in Business Administration/Management or Public health
5 years of experience in an active medical practice
1 year of Management experience
Medical Doctor OR
Doctor of Osteopathic Medicine (DO), Board certified in an American Board of Medical Specialties or Bureau of Osteopathic Specialists recognized specialty credentialed in a Highmark network.
A current, unrestricted state medical license (Delaware)Case Management
Telephone Skills
General Computer Skills
Clinical Software
Email Software (Outlook)
Managed Care
Language (Other than English)
Travel Required
Office-Based
Travel regularly from the office to various work sites or from site-to-site
Works primarily out-of-the office selling products/services (sales employees)
It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement:
This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.
In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company's Handbook of Privacy Policies and Practices and Information Security Policy.
This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law.
Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled/Sexual Orientation/Gender Identity ( )If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
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