Senior Medical Director - Highmark Health Options (Delaware)

Company :

Highmark Inc.

Job Description : 

JOB SUMMARY

This job leads a physician team and ensures that utilization management responsibilities are performed in accordance with the highest and most current clinical standards. The incumbent oversees a team of Medical Directors who are responsible for reviewing escalated cases electronically and using Medical Policy criteria sets, evaluating the medical necessity and appropriateness of the requested treatment of service. Depending on the nature of the case, telephonic peer to peer discussions may be required. The physician team must ensure compliance to NCQA, URAC, CMS, DOH, and DOL regulations at all times, and the Senior Medical Director will be responsible for ensuring that those measures are met. In addition to utilization review, the physician teams participate as physician members of CMDM multidisciplinary teams for case review. They will advise the multidisciplinary team on cases, particularly high-risk cases, through the team structure. Additionally, the physicians may be assigned special projects to help support and improve the care of our members. As the leader of these physicians, the Senior Medical Director will manage performance accordingly, delegate projects, and determine which team members will participate in which multidisciplinary teams. Also, as a physician leader, the incumbent consults other departments across the organization and with key provider networks as needed. They may serve on committees or project teams as a subject matter expert, depending on specialty and prior experience.

ESSENTIAL RESPONSIBILITIES

·       Perform management responsibilities including, but not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity. Plan, organize, staff, direct and control the day-to-day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority.

·       Participate on cross functional work teams as a physician subject matter expert and provide clinical leadership for relevant initiatives. At times, own/lead projects related to process improvement, system enhancements, and/or improvement of utilization management, quality of care and/or member services. Collaborate with providers to enhance care and population health management services.

·       Identify industry benchmarks and analyze and synthesize data and research to identify best practices relevant to clinical operations. Partner across the enterprise to develop, plan, and drive strategy.

·       Develop and lead a culture of continuous process improvement and care cost focus. Monitor, reinforce and model core behaviors that support and enable high-performing teams. Monitor and remediate regulatory compliance standards and develop tools and processes geared toward inter-rater reliability to promote consistent and appropriate utilization management decisions.

·       Other duties as assigned

EDUCATION

Required

·       Doctor of Medicine or Doctor of Osteopathic Medicine

Substitutions

·       None

Preferred

·       Master's Degree in Business Administration/Management or Public health

EXPERIENCE

Required

·       5 years of experience in an active medical practice

·       1 year of Management experience

Preferred

·       None

LICENSES AND CERTIFICATIONS

Required

·       Medical Doctor OR Doctor of Osteopathic Medicine (DO), Board certified in an American Board of Medical Specialties or Bureau of Osteopathic Specialists recognized specialty credentialed in a Highmark network.

·       A current, unrestricted state medical license (Delaware)

Preferred

·       None

SKILLS

·       Critical Thinking

·       Case Management

·       Customer Service

·       Listening

·       Telephone Skills

·       General Computer Skills

·       Clinical Software

·       Email Software (Outlook)

·       MS Word

·       Managed Care

Language (Other than English)

None 

Travel Required

0%  - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-Based

Teaches / trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Rarely

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required 

No

Lifting: up to 10 pounds

Rarely

Lifting: 10 to 25 pounds

Rarely

Lifting: 25 to 50 pounds

Rarely

Language (Other than English):

None

Travel Requirem