- Overseeing all initiatives and ongoing work in clinical programs, NCQA, HEDIS, credentialing, compliance with federal and state regulations, and management of grievance and appeal processes.
- Constantly evaluating and benchmarking of the resource-management system including utilization and case management.
- Monitoring/reviewing treatment recommendations by participating and non-participating providers for quality, appropriateness, and cost-effectiveness.
- Monitoring the constantly changing provision of care environment for changes in technique, technology, and protocols, and providing recommendations regarding plan member services.
- Reviewing quality-of-care issues and referring them to appropriate parties.
- Providing leadership and communication to physician groups and Mercyhealth leadership on care quality and efficiency issues.
- Staffing/chairing the Medical Management Committee and its subcommittees.
- Acting as NCQA project leader and providing management support for managed-care accreditation programs.
- Working with managed healthcare staff to develop/maintain measurement indicators.
- Submitting/presenting reports on utilization and quality activities to the health plan board of directors.
- Monitoring and ensuring the efficiency of the UM/QM staff.
- Directly supervising Medical Management and Quality Management, including the medical data analyst and the clinical pharmacist.
- Status as a medical doctor with appropriate state licensure.
- Current board certification in primary care or emergency medicine.
- Five or more years of experience in direct patient care.
- Five or more years of experience in managed care or similar administrative role.
- Demonstrated leadership and relationship-building skills.
- Relocation assistance available.
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Found in: Jobget US C2 - 19 hours ago
Helen Ross McNabb Center New Tazewell, TN, United StatesClaiborne Co School Based Mental Health Liaison · Help Others, Make a Difference, Save a Life. · Do you want to make a difference in people's lives every day? · Or help people navigate the tough spots in their life? · And do it all while working where your hard work is appreciate ...
Physician Medical Director for MercyCare Health Plan in Janesville, WI - Mercyhealth (FKA Mercy Health System)
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Description
The critical thought leader we select for this important role will be accountable for identifying and promoting key strategies for continuously improving the outstanding quality and efficiency of care expected by our members. In addition to controlling costs through utilization management, case management, disease management and other strategies, this professional will direct, implement, and support quality and utilization-management strategies and business plans for the MercyCare Insurance Company markets.
Responsibilities include:
Required Credentials
Other:
