Summary
 

Provides direct physician support. Oversees health and disease management programs. Oversees utilization management case evaluation for medical necessity. Reviews and communicates medical decisions. Interacts with network physician providers to resolve case-by-case complaints. Oversees medical aspects of vendor relationships. Assists in developing medical policy.

Description
 

Provides medical and administrative oversight of the health and disease management programs including budgeting, program strategic planning, and review of outgoing correspondence and printed materials. Provides presentations on health and disease management as assigned.

Provides direct physician support. Assists in compliance with regulatory bodies. Performs utilization management review functions including pre-admission review, continues stay review, procedure precertification, post-service reviews, emergency room visit reviews, and individual case management needs.

Serves as medical resource for quality improvement and National Committee for Quality Assurance (NCQA) and Health Plan Employer Data and Information Set (HEDIS) initiatives. Functions as liaison to medical community.

Acts as resource for providers/internal staff on medical policies. Educates providers on issues concerning medical policies, utilization specifications, coding/medical necessity issues. Conducts research into new/controversial medical procedures/technology as assigned to propose possible policy, coverage criteria, utilization specifications and coding recommendations.

Participates in medical review policy/quality programs and inter-reviewer reliability studies. Maintains familiarity with applicable regulations (state, federal) as well as any oversight agency/entity rules such as National Committee for Quality Assurance (NCQA), Department of Insurance (DOI), or URAC.

Additional:

• Complex Care/Case Management Review

• Support clinical nursing team in daily operations

• Perform peer to peer communication with facility providers

• Lead case management clinical rounds

• High-cost claimant data gathering and analysis

• Forward facing meetings for High-cost claimant reviews

• Clinical strategy meetings

• Present semi-annual and annual reviews on plan performance

Required Education: Doctorate in a job related field

Required Work Experience: 8 years broad clinical experience to include knowledge of utilization and medical review. Experience may include paid training.

Required Skills and Abilities: Demonstrated ability to direct multiple strategic projects. Excellent verbal and written communication skills. Excellent judgment, organizational, customer service, presentation skills. Excellent analytical or critical thinking skills. Knowledge of strategic concepts. Ability to persuade, negotiate, or influence others. Working knowledge of word processing, spreadsheet, and presentation software.

Required Software and Tools: Microsoft Office.

Required Licenses and Certificates: Active, unrestricted medical license from the United States and in the state of hire and current board certification in a recognized specialty.

Preferred Education: Bachelor's degree- Business Administration or Public Health

Preferred Work Experience: 2 years-medical data analysis/analytical capability to interpret statistical information.

Preferred Experience: Inpatient or previous Healthcare Case Management oversight experience preferred Care Mana