MEDICAL DIRECTOR – Long Term Care – OHIO health plan
Columbus - Toledo - OR Fairlawn location
Physician looking for a puposeful career will enjoy this chance to make a difference in care for the frail and underserved population.
Newly created role will collaborate with the VP of Clinical Programs to direct and coordinate the physician component of the utilization management functions for the Ohio health plan.
Position will oversee the LTC program, providing expertise in LTC, involved in working closely with CM Staff. Conducting visits periodically with providers/nursing facilities.
Medical Director will be involved in PA reviews and peer to peer reviews as well as participating in quality meetings. Will collaborate on policy development for the LTC program
- Provides medical leadership for utilization management activities and medical review activities pertaining to utilization review, quality assurance, medical review of complex, and controversial or experimental medical services such as transplants utilizing the services of consultants
- Performs case reviews and appeals for all health plans.
- Assists VP of Clinical Programs in planning, 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.
- 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.
- Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment
-Requires a Medical Doctor or Doctor of Osteopathy
-Board certified preferably in a primary care specialty (Internal Medicine, Med/Peds, Family Practice, Pediatrics or Emergency Medicine) or other specialty familiar with Medicare patients.
-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.
-The candidate must be an actively practicing physician.
License/Certifications: Board Certification through American Board Medical Specialties.
Current state medical license without restrictions.
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Keywords: MD, managed care