Medical Director HEALTH PLAN REMOTE
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Job Location:
Portland, TX - USA
Monthly Salary:
Not Disclosed
Posted on:
2 days ago
Vacancies:
1 Vacancy
Job Summary
Join Martins Point Health Care - an innovative not-for-profit 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 provides professional leadership and direction to the utilization & cost management and clinical quality management functions of Martins Points Health Plans. The Medical Director works collaboratively with other plan functions that interface with Medical Management such as Health Management Quality Network Management Member Services benefits & claims management and Compliance. They assist in short and long-range program planning quality management and external relationships. The Medical Director reports to the VP Medical Director and works closely with the other Health Plan leaders.
Job Description
PRIMARY DUTIES AND RESPONSIBILITIES
Employees are expected to work consistently to demonstrate the mission vision and core values of the organization.
- Serves as a key implementer of the Health Plans Triple Aim strategy vigorously and accurately driving the cost management component of the Triple Aim.
- 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.
- Performs medical necessity reviews of requests for health plan-covered services (benefits). Reviews disputes and appeals of said services for clinical appropriateness.
- 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 regarding cost management and develops a plan and schedule for communication with outliers.
- Develops an in-depth 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 goals and strategic initiatives in particular utilization and cost management goals MLR (budget vs. actual and performance versus prior years) inpatient days/1000 SNF days/1000 and clinical quality improvement (QI) objectives including HEDIS.
POSITION QUALIFICATIONS
There are additional competencies linked to individual contributor provider and leadership roles. Please consult with your leader to discuss additional competencies that are relevant to your position.
Education
- MD/DO
Licensure/certification
- 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.
Experience
- Board certified physician with post-graduate experience in direct patient care required
- Medical leadership in or focused activity of a Health Plan (preferred)
- 2-5 years of Experience in utilization management in a health plan setting is preferred
Knowledge
- Knowledge of process improvement tools
- Deep knowledge and practical understanding of Health Care systems and Managed Care concepts
- Knowledge and deep commitment to performance-based Health Plan systems
Skills
- 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
Abilities
- Demonstrates an understanding of and alignment with Martins Point Values.
- Demonstrated ability to manage and develop staff
- Willingness to explore innovative methods of providing medical management
- Supports the culture and models the MPHC values
This position is not eligible for immigration sponsorship.
We are an equal opportunity/affirmative action employer.
Martins Point complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. 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
Do you have a question about careers at Martins Point Health Care Contact us at:
Required Experience:
Director
Key Skills
- EMR Systems
- Post Residency Experience
- Occupational Health Experience
- Clinical Research
- Managed Care
- Primary Care Experience
- Medical Management
- Utilization Management
- Clinical Development
- Clinical Trials
- Leadership Experience
- Medicare
