REMOTE - Associate Medical Director
REMOTE - Associate Medical Director
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Job Description
Join Martins Point Health Care an innovative notforprofit health care organization offering care and coverage to the people of Maine and beyond. As a joined force ofpeople caring for people Martins Point employees are on amission to transform our health care system while creating a healthier community. Martins Point employees enjoy an organizational culture of trust and respect where our values taking care of ourselves and others continuous learning helping each other and having fun are brought to life every day. Join us and find out for yourself why Martins Point has been certified as a Great Place to Work since 2015.
Position Summary
The Medical Director (MD) provides clinical leadership and direction to the utilization & care management functions of Martins Points Health Plans. The MD works collaboratively with other plan functions that interface with Medical Management such as Health Management Compliance and Appeals Network Management Member Services benefits & claims management and Compliance. In this role there is the opportunity to assist in or drive short and longrange clinical programming quality management and external relationships. The Medical Director reports to the Vice President Health Plan Medical Director and works closely with the other Health Plan leaders.
Job Description
Key Outcomes:
- Responsible and accountable to the Health Plan Medical Director for helping to manage health plan medical costs by assuring clinically appropriate health care delivery for health plan products and services utilizing EvidenceBased Guidelines to ensure the right service at the right time and place for each member
- Performs medical necessity reviews of requests for health plancovered services (benefits). Reviews disputes and appeals of said services for clinical appropriateness and in compliance with government program rules
- Contributes to case reviews to ensure the quality and safety of care and services delivered to Martins Point Health Plan members.
- Assists in the construction of the annual Utilization Management Care Management and Disease Management Program Descriptions and works to ensure the programs meet accreditation and regulatory standards (e.g. NCQA CMS TRICARE)
- Participates in medical policy review and policy development.
- Works with Informatics Network Management and Medical Economics to create and maintain a system where Network providers are properly assessed in regard to cost management and develops a plan and schedule for communication and solutioning with outliers.
- Develops an indepth understanding of ACOs and contributes to their management and strategic deployment.
- Provides support to Health Plan risk adjustment activities as needed.
- Is conversant with Health Plan key performance metrics in particular utilization and cost management goals MLR inpatient days/1000 SNF days/1000 and clinical quality improvement (QI) objectives including HEDIS and how to drive improvement in these areas
Education/Experience:
- Board certified physician with postgraduate experience in direct patient care required
- Medical leadership in or focused activity of a Health Plan (preferred)
- Knowledge of process improvement tools
- Experience in Health Plan utilization management
- Experience in Medicare Advantage and/or TriCare preferred
Required License(s) and/or Certification(s):
- Active and unrestricted license to practice medicine in Maine or New Hampshire; or another U.S. state with eligibility to apply for and obtain additional state licensure.
- Current or ability to have some active clinical work with patients
Skills/Knowledge/Competencies (Behaviors):
- Deep knowledge and practical understanding of Health Care systems and Managed Care concepts
- Knowledge and deep commitment to performancebased Health Plan systems
- Good analytic skills with the ability to identify meaningful trends and targets for improvement
- Excellent interpersonal skills and demonstrated ability to establish rapport and working relationships with providers service vendors and internal staff
- Willingness to explore innovative methods of providing medical management
- Supports the culture and models the MPHC values
We are an equal opportunity/affirmative action employer.
Do you have a question about careers at Martins Point Health Care Contact us at:
Required Experience:
Director
Employment Type
Full-Time
