Medical Director, Utilization Management Review, Internal Medicine

Provide organizational leadership in the operational areas of care management, utilization review, appeals, quality improvement and related policy and practice initiatives in collaboration with the Corporate Medical Director(s), Utilization Management and the Vice President, Utilization Management Physician.

The following responsibilities are in regards to members with medical conditions and their providers:
•   Identifying and implementing evidence-based practice guidelines throughout the provider network. Overseeing the quality of clinical care for network and non-network providers.
•    Engaging the provider network in Continuous Quality Improvement through the diffusion of practice standards, and through an internal quality assurance program that measures network provider performance against standards of high quality, especially the performance standards embodied in the HEDIS program.
•    Assuring a high-performing Medical Management system that adheres to the terms of contracts and all relevant regulatory requirements.  
•    Utilizing evidence based standards in making coverage determinations.

Accountabilities:
•    Ensures the provision of quality and clinically sound services to all Enrollees by associates and Providers.
•    Serves as medical advisor and manager for all clinically related activities.
•    Assures that organization medical policies and procedures adhere to contractual obligations.
•    Performs clinical case reviews in conjunction with Medical Excellence Department.
•    Demonstrates knowledge of prescribed and established medical procedures and practices.
•    Maintains familiarity with federal, state and local regulations that may pertain to the medical and clinical operations. 
•    Provides leadership in the development and implementation of medical policy as it relates to health management. 
•    Maintains compliance with applicable regulatory guidelines, AmeriHealth Caritas clinical policies and procedures, and contractual obligations.
•    Manages day-to-day operations and monitors the integration and processing of members to optimize appropriate use of behavioral and physical health services.
•    Participates with Quality Improvement and Medical Excellence in the identification and analysis of medical and behavioral health information in order to develop interventions to improve clinical effectiveness of medical management strategies.
•    Works closely with a multidisciplinary team to ensure behavioral health management and quality management programs are meeting contractual obligations.
•    Works with the leadership of the Quality Improvement and Medical Excellence departments to develop competent clinical staff.
•    Trains staff on medical issues and provide consultation to staff as appropriate.
•    Assists Integrated HealthCare Managers in assessing members’ need for case management services.
•    Attends case management meetings and monthly rounds as scheduled.
•    Collaborates with the integrated case management team, during scheduled meetings and informally as needed.
•    Thoroughly documents all care coordination activity in the member medical record in the electronic case management documentation system. 
•    Adheres to AmeriHealth Family of Companies (ACFC) policies and procedures and supports and carries out the ACFC mission and values.

Education/Experience:
•    Medical Degree (M.D. or D.O.) Must be licensed to practice in the state(s) assigned as a medical director/doctor and recognized by the proper licensing authority. 
•    Must be clear of any sanctions by the applicable state or Office of the Inspector General.
•    Must not be prohibited from participating in any federally or State funded healthcare programs.
•    Active Board Certification in Internal Medicine or Family Medicine.
•    2+ years full-time experience practicing medicine.
•    3+ years in on or a combination of the following:
      o    Full-time experience as an administrator in a Medicare or state-level Medicaid program, Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), large Health Care Organization, health plan or any combination thereof, or
      o    Full-time medical facility administration or medical facility management experience
•    State Management organization (SMO) experience preferred.
•    Strong written and oral communication skills-required.
•    Demonstrated competency in use of healthcare data.
•    Demonstrated excellent interpersonal communication skills and presentation skills.
•    Experienced in conflict resolution and negotiation.
•    Understanding of and expertise in quality improvement and medical economics.
•    Strong leadership skills.
•    Excellent analytical and problem solving skills.
•    Demonstrated ability to access department’s work quality and develop / implement process improvements to achieve regulatory and oversight compliance.
•    Maintain current knowledge of and applies all applicable licensing, regulatory and industry standards.