Daily utilization management activities for all lines of business including Medicare. Assist in the recruitment of participating providers, support provider relations activities, monitor performance of participating physicians and assist in the development and implementation of medical policy. Participate in the attainment of quality management goals to meet or exceed quality standards as established by all external agencies. Participate in the identification and analysis of medical information from multiple sources in order to develop interventions to improve the quality of care and outcomes.
Manages all major clinical and quality program components of the health plan. Ensures timely medical decisions, including after hours consultation as needed. Provides supervision and ensures sufficiency of the health plan provider network. Ensures compliance with State and local reporting laws on communicable diseases, child abuse, neglect, etc.