...MEDICAL DIRECTOR- Greater St Louis, MO
..........National health plan is growing and diversifying in the MISSOURI market. A physician seeking a purposeful career with an opportunity to make a difference in the quality of care and access to care will thrive in this role.
- Medical Director will collaborate with the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the FL health plan. Provides medical leadership of all for UM, cost containment, and medical QI activities. Be part of planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members. 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.
- Participates with the Chief MD in the functioning of the physician committees and 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
- MD or DO - Board certified (Ideal specialties: : Internal Medicine, Pediatrics, Family Practice or OB)
- Strong Quality Background
- Clinical Practice experience 10-12 years minimum
- The candidate must be an actively practicing physician.
- Previous experience within an MCO and/or conducting medical reviews is preferred.
- Willing to practice clinically 1 day per week and work 4 days in the office
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