Medical Director

Description: Position Purpose: Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit. Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities. Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services. Supports effective implementation of performance improvement initiatives for capitated providers. Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members. Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements. Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership. Oversees the activities of physician advisors. Utilizes the services of medical and pharmacy consultants for reviewing complex cases and medical necessity appeals. Participates in provider network development and new market expansion as appropriate. Assists in the development and implementation of physician education with respect to clinical issues and policies. Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components. Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care. Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality. Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment. Develops alliances with the provider community through the development and implementation of the medical management programs. As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues. Represents the business unit at appropriate state committees and other ad hoc committees Responsible for the provider performance program by persuading physician groups, local markets and medical staff of the value of the program for members improved quality of care, lower cost of services and improved financial reimbursement for providers who are successful in managing quality, access and overall costs. Monitors competitor products and internal provider performance reporting capabilities and responds with recommended enhancements Accountable for achieving performance results in value based care by engaging, influencing and supporting physicians. Engages with providers in joint operating committees and builds relationships with clinical leadership of provider collaboration groups.Responsible for collaborating with providers in a region.Designs and develops market interventions leveraging existing tools that will drive performance in value-based care. Provides expertise, captures and shares best practices across regions to provider partners as well as IlliniCare medical directors. Collaborates with provider engagement team to bring insight, innovation and opportunities that help drive performance. Develops understanding of value-based contracts across lines of business in a region and around cost of care and analytic tools and reporting. Qualifications: Education/Experience: Medical Doctor or Doctor of Osteopathy, board certified preferable in a primary care specialty (Internal Medicine, Family Practice, Pediatrics or Emergency Medicine). The candidate must be an actively practicing physician. Previous experience within a managed care organization is preferred. Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is preferred. Experience treating or managing care for a culturally diverse population preferred. 1122794
Salary Range: NA
Minimum Qualification
Not Specified years

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