Associate Medical Director

Job ID: J103188
Location: Parkersburg, WV, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Jul 18, 2017

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Description

JOB SUMMARY

This job provides clinical support to the Medical Management & Policy team to ensure that utilization management activities are performed in accordance with the highest and most current clinical standards.  Responsible to review cases and evaluate the medical necessity and appropriateness of the requested treatment of service.  Responsible for compliance to NCQA, URAC, CMS, DOH, and DOL regulations. Responsible for appropriate application of Medical Policy and criteria sets. The incumbent provides clinical consultation to the Care Management and Health Coach staff to support the various utilization management and health coach activities. Work from home may be offered if incumbent has prior utilization management experience and prior working from home experience within a large health plan organization.

ESSENTIAL RESPONSIBILITIES

  • Serve as a resource for information and consultation on the issues related to utilization management and clinical services.
  • Retain involvement in all aspects of the medical management process involving medical necessity and appropriateness determinations.
  • Perform initial determinations, appeals, grievances, peer to peer, pharmacy and other reviews, as assigned
  • Participate in protocol and guidelines development to ensure consistency in the review process. 
  • Ensure that all aspects of the medical management process are consistent with community standards of care.
  • Compose clear and concise clinical rationales for members and provider determination notifications.
  • Assure high performance standards by meeting targets set by management.
  • Implement action plans designed to achieve and enhance compliance to accreditation standards in accordance with NCQA, URAC, CMS, DOH, and DOL regulations.
  • Support Care and Case managers by providing consultation and staff education via clinical presentations and case management conferences.
  • Interact effectively with members, practitioners/providers, colleague and care and case managers.
  • Conduct problem solving the scope and frequency of these opportunities is diverse, frequently involving coordination with internal and external customers.  The incumbent has a significant degree of independence in handling day to day duties.  
  • Serve as a resource for information and consultation on the issues related to utilization management and clinical services.
  • Retain involvement in all aspects of the medical management process involving medical necessity and appropriateness determinations.
  • Perform initial determinations, appeals, grievances, peer to peer, pharmacy and other reviews, as assigned
  • Participate in protocol and guidelines development to ensure consistency in the review process. 
  • Ensure that all aspects of the medical management process are consistent with community standards of care.
  • Compose clear and concise clinical rationales for members and provider determination notifications.
  • Other duties as assigned or requested.

QUALIFICATIONS

Required

  • MD or DO with an unrestricted PA, WV, DE medical license
  • Board certified in an American Board of Medical Specialties or Bureau of Osteopathic Specialists recognized specialty
  • Must be credentialed in an Organization network
  • Four years’ experience required in an active clinical practice

Substitutions

  • None

Skills

  • Excellent written and verbal communication skills
  • Ability to interact with all levels of the organization
  • Ability to interact with external customers and providers
  • Ability to analyze data, measure outcomes and develop action plans
  • Highly effective interpersonal skills
  • Ability to intervene in crisis situations and multi-task
  • Computer and software knowledge and skills

SCOPE OF RESPONSIBILITY

Does this role supervise/manage other employees?

No

WORK ENVIRONMENT

Is Travel Required?

Yes

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org

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