Works closely with matrix partners to manage utilization management and case management activities for all lines of business including Medicare. Assists in the recruitment of participating providers, supports provider relations activities, monitors and actively manages performance of participating physicians and assists in the development and implementation of medical policy. Works in conjunction with the Senior Medical Director to attain quality management goals that meet or exceed quality standards as established by all external agencies. Participates in the identification and analysis of medical information from multiple sources in order to develop interventions to improve the quality of care and outcomes. Provides innovative solutions for key business drivers and leads efforts to improve upon these metrics.
Reports to: State President, Missouri
Location: St. Louis, Springfield, or Columbia, MO
- Leads medical management and quality initiatives for assigned area to include utilization management through a matrix partnership, Quality Improvement & accreditation initiatives, Pharmacy utilization, quality and cost management of provider network, and program leadership for various corporate and local initiatives designed to improve member care and minimize unnecessary costs.
- Interprets medical policy for associates to facilitate the healthcare needs of plan members.
- Works closely with P&L owners to develop strategies to change member and provider behavior to improve quality of care, while also reducing medical costs.
- Works closely with and influences key business partners within a matrix organization faced with competing priorities.
- Makes recommendations (based on daily activities of evaluating members' care) about medical policy, clinical criteria and administrative process.
- Chairs medical policy, credentialing and related health plan committees.
- Works with the medical community to assist in the development and maintenance of a strong, quality network of providers.
- Supports provider relations and risk contracting through education, provider visits and problem resolution.
- Visits targeted providers for recruitment, as well as performing proactive provider visits as scheduled.
- Works with quality management and medical cost analysis staff to identify trends in treatment and outcomes by interpreting various data.
- Reviews provider and member complaints, assist in resolution, and make recommendations for changes.
- Utilizes clinical expertise to assist in the development of care improvement programs to improve health outcomes for the member population.
- Manages and develops direct reports who include directors and/or managers.
- A Doctor in Medicine (MD) Or D.O. from an accredited school of medicine recognized by national medical regulatory bodies in the United States required.
Licenses and Certifications:
- Board Certification required.
- Current license without restrictions in working state or the ability to obtain that license required.
- 7 years of experience in direct patient care and a strong working knowledge of managed healthcare required.
- Substantial experience and expertise in the development of medical policies, procedures and programs is required.
- Demonstrated success implementing utilization and quality improvement strategies /techniques and experience with physician behavior modification is required.
- Qualifications to perform clinical oversight for the services provided by the health plan to include but not limited to: Education, training or professional experience in medical or clinical practice, is required.
- Past participation in hospital managed care or medical practice UM committee preferred.
- Demonstrated success implementing utilization tools/techniques and experience with physician behavior modification.
- Intermediate proficiency with Microsoft Outlook, Word, and Excel required.