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Medical Director- Utilization Review role Medicaid/Medicare

Company: Job Juncture
Location: Saint Louis
Posted on: September 15, 2018

Job Description:

We are in search of a Medical Director who is and actively practicing Board Certified Physician preferably in a primary care specialty and will consider Board Certifications in the following specialties:  Internal Medicine, Family Practice, Pediatrics or Emergency Medicine. Our client prefers you do have expereince working in a managed care setting.
 
This is a role where you are directing and coordinating the medical management, quality improvement and credentialing functions.  You should be willing to practice clinically ONE day a week.
 
We will also consider those Board Certified in Behavioral Health however we can only consider those who are Board certified by the American Board of Psychiatry and Neurology. Current state medical license without restrictions. Board certification in general psychiatry or child psychiatry. 5+ years of experience working in behavioral health managed care or behavioral health clinical settings, with at least 2 years in a clinical setting. Certification in addiction medicine or in the sub-specialty of addiction psychiatry preferred.
 
Our client may consider candidates requiring Visa Sponsorship.
 
Here is what a typical day would look like for you:

  • 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. 
    This is NOT a remote opportunity. To be considered you should not currently have a non-compete clause in your current contract. This position reports to the Senior Director.
     
    Our client is located in a suburb of St. Louis, MO.
    Interested? Please email your resume to us and we will promptly follow up with you should you meet the qualifications of this role.
     
     

    Keywords: Job Juncture, St. Louis , Medical Director- Utilization Review role Medicaid/Medicare, Executive , Saint Louis, Missouri

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