Medical Director - Oklahoma City, OK, United States - Oklahoma AG

Description

Job Posting Title

Agency

Supervisory Organization

Job Posting End Date (Continuous if Blank)

Note: Applications will be accepted until 11:59 PM on the day prior to the posting end date above.

Estimated Appointment End Date (Continuous if Blank)

Full/Part-Time

Job Type

Compensation

Job Description

Basic Purpose

Under general direction of the Chief Medical Officer and the Senior Medical Director, the Medical Director is responsible for leadership, medical necessity reviews, and direction as assigned to promote policies and standards that lead to more efficient and appropriate delivery of quality health care to beneficiaries and staff.

Typical Functions

• Make determinations of medical necessity by review of clinical records and direct contact with providers as necessary.
• Make determinations regarding the appropriateness and quality of care by review of clinical records and through direct contact with providers as necessary.
• Review prior authorization requests for medical services based on review of clinical data submitted, policy, and consistent with current Medical Professional Services Unit guidelines, and the currently available medical evidence.
• Review requests for Private Duty Nursing (PDN) services according to current PDN rules.
• Review requests for Out of State (OOS) services according to the current OOS rules. Participate in developing relationships with Oklahoma medical schools specialists and private practice specialists to improve access and capacity for SoonerCare members to be treated in state where capability and capacity exist.
• Provide medical advice and review to the Program Integrity (PI) unit in conducting PI audits. Review PI audits in the reconsideration phase and participate as a medical witness in PI appeals.
• Research areas of medicine that are unfamiliar or require updating to ensure policies and procedures are based on evidence and the current standard of care.
• Become familiar with and develop relationships with the appropriate staff in other divisions in order to fulfill the responsibilities of medical director.
• Participate in the peer-to-peer email line by communicating with providers as assigned, providing information, guidance, and possible solutions as appropriate.
• Summarize documentation and records for discussion internally and to present as needed at beneficiary appeals before the ALJ and other venues as directed.
• Provide clinical expertise and input as requested to Legal, Policy, Audits, Provider Services, Care Management, Behavioral Health and other divisions as requested and as appropriate to promote efficient delivery of and access to quality medical care.
• Regular and consistent attendance at the assigned work site, as well as the ability to perform all job-related travel, is essential to successful performance in this position.
• Provide guidance and support to the Director of Quality Assurance regarding the quality of care delivered, determining quality of care and medical home standards and assist with claims review guidelines. Assists in education of providers on quality issues.
• Provide support as needed to the Director of the Medical Authorization and Review Unit to ensure decisions are being made based on evidence-based guidelines and agency policy.
• Review claims for beneficiaries in special categories, e.g. aliens, disabled, Soon to be Sooners, etc. to ensure they meet federal and state guidelines that include clinical decision making.
• Consult and coordinate with other organizations or agency medical directors, clinicians, administrators, etc. to promote the welfare of our beneficiaries.
• Advise and assist agency, based on clinical understanding of the services provided, in setting payment guidelines for special, new, or unusual services.
• Recommend allowable reimbursement levels for new procedures based on comparable procedures, if no RVU value has been established yet are determined medically necessary.
• Participate in periodic on-site operational compliance audits and readiness reviews and PCP/CM provider audits as assigned.
• Prepare and deliver presentations to providers, advocates, committees, boards, legislators, and other constituencies as required.
• Communicate agency policies and procedures to primary care providers, specialists, hospital staff and administrators, and other clinicians as needed. Address the issues raised by these providers either directly or by appropriate referral to other agency staff.
• Advise and assist Provider Services Unit in education and provider training.
• Identify issues that affect provider participation and ultimately member access to providers. Offer recommendations and promote policies and procedures that remove barriers to provider participation and lead to better access to care.
• Participate in special projects such as the Health Management Program and C-Section reduction project, participation in MMDN as requested.
• Other duties as assigned.

T ravel : Local and overnight travel by both public and private conveyance is an essential requirement of this position.

Education and Experience

• Currently active MD or DO license in the state of Oklahoma AND
• At least 3 years of clinical practice

Preference may be given to candidates:

• Supervisory experience in group physician/hospital environment
• Experience and knowledge of Medicaid programs
• Advance degree in related field
• Previous experience in medical review
• Previous experience as a medical director
• Board Certification

Special Requirements

• Must be able to remain sitting for prolonged periods at a desk and working on a computer.
• Must be able to move or lift up to 15 pounds at various times.

Work Environment :

• The office work environment includes regular exposure to general office equipment such as computer equipment, phones, and copy machines.

Benefits Highlights

OHCA is proud to provide a comprehensive benefits package designed to support our employees and their dependents. Our benefits include:

• Generous state paid benefit allowance to help cover insurance premiums.
• A wide choice of health insurance plans.
• Optional flexible spending accounts for health care expenses or dependent care.
• Employee assistance program and health and fitness programs.
• 11 paid holidays.
• 15 days of vacation and 15 days of sick leave the first year.
• Retirement Savings Plan with a generous contribution.
• Longevity Bonus for years of service.
• Public Service Loan forgiveness and educational assistance reimbursement program.
• Training opportunities for CEU requirements.

Accommodation Statement:

The Oklahoma Health Care Authority complies with applicable State and Federal civil rights laws and does not discriminate. All qualified applicants will receive consideration for employment without regard to race, color, sex, religion, disability, age, national origin, or genetic information. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact the Civil Rights Coordinator at

Notice to applicants:

Please add to the address book or "safe-senders" list in your email. All correspondence will come from this address. Be sure to check your junk folder. If you have questions about the status of your application, you can contact the HR team at

Note: Applications will be accepted until 11:59 PM on the day prior to the posting end date above.

Current State of Oklahoma employees: must apply for open positions through their Workday account on the Internal Website only.

To apply internally, Go to "Menu" from Workday home screen, Select "Careers," then Click on "Find Jobs-Internal State of Oklahoma."

Under Agencies, Select "807 – Health Care Authority." Select the position you would like to apply, complete the entire job application, and attach your resume with your job application.

**A complete job application includes: Resume/CV attached with a complete work history and education .**

Equal Opportunity Employment

The State of Oklahoma is an equal opportunity employer and does not discriminate on the basis of genetic information, race, religion, color, sex, age, national origin, or disability.

Current State of Oklahoma employees must apply for open positions through their Workday account. Go to Careers app on WD home screen> Click on 'Find Jobs-Internal State of Oklahoma'.