Medical Director - Wheeling - The Health Plan of West Virginia Inc

    The Health Plan of West Virginia Inc
    The Health Plan of West Virginia Inc Wheeling

    3 days ago

    Default job background
    Full time
    Description

    Job Description

    Medical Professionals oversee healthcare services for plan members, ensuring cost-effective quality care. The Medical Director is responsible for medical direction of quality management and utilization management programs at The Health Plan. This will be a dual leadership role with Directors of Utilization, Quality Management, and Pharmacy Management.

    Required:

    1. An active physician license without restriction.
    2. Meets all THP credentialing requirements.
    3. Three years managed care experience in an HMO setting preferred.
    4. Board certification.
    5. Minimum of five years postgraduate clinical experience.

    Desired:

    1. Basic computer literacy.
    2. Prior leadership roles while in clinical practice are desirable.
    3. Demonstrated ability to work harmoniously with other professionals and non-professionals.

    Responsibilities:

    1. Provide Physician oversight for activities related to the company's Utilization Management, Disease Management, and Quality Management programs, ensuring compliance with NCQA, Medicare, Medicaid, and other regulatory entities.
    2. Establish best medical practices for care provided to members through participation in the development of clinical practice guidelines and selection of suitable proprietary criteria and clinical pathways.
    3. Provide education on Health Plan utilization management and quality management protocols and initiatives to individual physicians or physician groups.
    4. Carry out specific functions as outlined in the Utilization Management Program, including:
    • a. Leadership role in the development and implementation of the Utilization Management Program, assisting in the annual work plan and program evaluation, and serving as chairperson and/or member of various utilization management committees.
    • b. Review of clinical utilization and delivery of acute care to members daily, maintaining interaction with hospital review, case managers, care managers, disease managers, pharmacy managers, claims managers, and other staff.
    • c. Review of cases where medical appropriateness is questioned and overall responsibility for authorization or non-authorization based on medical appropriateness of healthcare services requested.
    • d. Availability to communicate telephonically with practitioners in case review matters.
    • e. Availability for 24-hour coverage for case review matters as needed.
    • f. Participation in the functioning of the plan appeal and grievance procedures.
    1. Carry out specific functions as outlined in the Quality Management Program, including:
    • a. Leadership role in the development and implementation of the Quality Management Program, assisting in the annual work plan and program evaluation, and serving as chairperson and/or member of various quality management committees.
    • b. Monitoring, evaluating, and validating clinical quality issues and referring them to internal staff, committees, or institutional regulatory bodies.
    • c. Collaboration in organizing a continuous quality improvement mechanism for The Health Plan and identifying specific clinical goals and objectives for focus or priority.
    • d. Guidance and resource to the Quality Management Program in data collection and analysis related to quality studies and surveys, participating in qualitative analysis to identify barriers and corrective actions.
    1. Work directly with Network Development staff to develop and coordinate effective provider education/intervention programs, providing input into provider training and education programs, reviewing provider manuals, and direct contact with providers as needed.
    2. Perform other duties and special projects assigned to accomplish the goals of the organization.
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