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Medical Director

at Network Health

Posted: 1/22/2020
Job Status: Full Time
Job Reference #: 69597d69-208a-4e5c-bd3b-63f8376f6c07
Keywords: director

Job Description

Network Health’s success is rooted in its mission to create healthy and strong Wisconsin communities. It drives the decisions we make, including the people we choose to join our growing team. Network Health is seeking a Medical Director to join the growing team. This individual will report to the Chief Medical Officer and works in a team with other leaders in Population Health. The Medical Director is responsible for day-to-day support of Utilization Management, Credentialing, Quality, Case Management and NCQA processes that require clinical input. This leader will be instrumental in Network Health achieving their goals of market expansion, product expansion, and participation in the Healthcare Exchange. This key physician leader will be responsible for first level decisions related to utilization management, act as a coach to colleagues and be a final decision maker (when necessary) for case management issues. S/he will be an important and contributing member/leader of the Medical Policy Committee, Peer Review and Credentials Committee. 

Job Responsibilities:

  • Demonstrates commitment and behavior aligned with the philosophy, mission, values and vision of Network Health
  • Contributes to, supports and executes short, medium and long-range strategic plan
  • Provides input and support for the development of the annual medical expense management plan; accountable for the achievement of utilization and cost targets
  • Identifies, prepares and distributes appropriate and required data, records and reports
  • Ensures medical compliance with all regulatory and accreditation requirements
  • Participates in sales process through community and employer specific presentations
  • Identifies potentially unnecessary services and care delivery settings and recommends appropriate alternatives
  • Supervises all clinical decision making
  • Provides guidance and instruction to facilitate completion of tasks and projects
  • Assists with employee selection and promotion process
  • Conducts performance reviews and provides guidance to resolve performance issues in a timely and positive manner
  • Provides timely communication of and ensures adherence to company policies and procedures
  • Participates directly in prior authorization review, concurrent and retrospective review processes
  • Reviews actual and proposed medical care and service requests and makes coverage decisions in accordance with NH policy, procedure, and benefit plan designs.
  • Works collaboratively in the development, implementation, ongoing monitoring, and outcome analysis of the Quality Improvement Program and responds to physicians and other provider inquiries and complaints within the guidelines of the Quality Improvement Program.
  • Participates in development and evaluation of clinical programs to identify and manage members for specific case management and or disease management programs.
  • Supports the clinical staff in management of members that are at risk, high risk and high cost
  • Maintains up to date knowledge of new information and technologies in medicine and their application to the health plan.
  • Directly supports NCQA accreditation processes and maximization of HEDIS scores to meet the highest standards.
  • Monitors the quality of care/services provided in assigned areas and strives to continuously improve the service provided to customers. 

Job Requirements:

  • MD or DO – required.
  • Management courses or courses in managed care preferred
  • Participation in management committees in a practice or hospital setting required
  • Experience as a medical director preferred
  • Experience and knowledge of managed care principals, utilization management, case management, quality, and population health.
  • Board certified in an ABMS medical specialty
  • Willingness and ability to be licensed in the state of Wisconsin
  • Expertise in Commercial, Medicare and ASO products and the ability to work as an internal consultant to product development, sales and provider network development.
  • Knowledge of the Health Care Reform environment and understanding of current thinking on effective strategies for health plans and integrated systems.

Network Health is an affirmative action and equal opportunity employer.

*WARNING: Please beware of phishing scams that promote work-at-home opportunities and which may also pose as legitimate companies. Please be advised that Network Health recruiter will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for a role with our company. All of our positions require that you first complete an online application.