Medical Director Health Plan
Company: Direct Jobs
Location: Austin
Posted on: March 18, 2023
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Job Description:
Details Posted: 10-Mar-23Location: Austin, TexasSalary:
OpenCategories: Physicians/Surgeons Internal Number:
23002211rxv_29_2 JOB SUMMARY
Responsible for managing Health Plan medical costs and assuring
appropriate health care delivery for plans and members. Is
accountable to provide professional leadership and direction in the
utilization/cost management (UM) and clinical quality improvement
(QI) of the Health Plan, as measured by benchmarked UM and QI
goals. Works collaboratively as a clinical resource to other plan
functions that interface with medical management such as provider
relations, member services, benefits, claims management, etc.
Carries out medical policies at the Health Plan consistent with
NCQA and other regulatory bodies.
ESSENTIAL FUNCTIONS OF THE ROLE
Identify opportunities for corrective action plans to address
issues and improve plan and network managed care performance.
Collaborate with Provider Networks and Medical Director team in
creating and maintaining programs that incentivize providers to
achieve selected utilization/cost and quality outcomes.
Participate in the retrospective review and analysis of Health Plan
performance from summary data of paid claims, encounters,
authorization logs, compliance and grievance logs, and other
sources.
Provide periodic written and verbal reports and updates as required
in the Quality Management Program description, the Annual QI Work
Plan.
Assure plan conformance with legal and regulatory requirements;
support NCQA qualification activities, including site visits and
response to accrediting and regulatory agency feedback.
Support pre-admission review, utilization management, concurrent
and retrospective review process and case management.
Participate in risk management, claims administration, pharmacy
utilization management, catastrophic case review, outreach
programs, HEDIS reporting, site visit review coordination, triage,
nutrition service review, provider orientation, credentialing,
profiling, etc.
Conduct quality improvement and outcomes studies as directed by the
state and federal regulatory agencies, the Quality management
Committee, Medical Advisory Committee, Peer Review Committee, and
management.
Support grievance process, as led by Chief Medical Offices,
insuring a fair outcome for all members.
Monitor member and provider satisfaction survey results and
implements changes as needed to increase satisfaction and assure
that satisfactory relationships are maintained between network and
plan participants.
May be asked to chair various Health Plan committees, such as
Quality Management subcommittees on Peer Review or
Credentialing.
Promote wellness and ensure programs of prevention, education and
outreach to members and providers consistent with company's
mission, vision, and values.
Perform and oversees in-service staff training and education of
professional staff.
Contribute to the development of strategic planning for existing
and expanding business; recommend changes in program content in
concurrence with changing markets and technologies.
Participate in key marketing activities and presentations, as
necessary, to assist the marketing effort.
Performs other position appropriate duties as required in a
competent, professional, and courteous manner as directed by
management.
KEY SUCCESS FACTORS
5 years of clinical experience in the practice of medicine, 2 of
which have been in medical and/or health administration, preferably
in a managed care setting.
3 years of management and/or clinical experience in a managed care
environment.
Management skills to meet the organizational goals.
Must possess excellent communications skills to interface with
providers, staff, and management.
Knowledge of medical, quality improvement and UM practices in a
managed care environment.
knowledge of regulatory and accreditation agencies and
requirements.
Able to manage multiple priorities and deadlines in an expedient
and decisive manner.
Able to manage difficult peer situations arising from medical care
review.
Appreciation of cultural diversity and sensitivity towards target
population.
Up-to-date knowledge of new information and technologies in
medicine, and their application to Health Plans, as well as
computer applications, including productivity tools and Care
Management Plantforms.
Must be available during normal working hours to make coverage
decisions. Additional after hours availability may be required to
review emergently or urgently needed services.
BENEFITS
The highlights of our competitive benefits package include:
- Immediate eligibility for health and welfare benefits
- 401(k) savings plan with dollar-for-dollar match up to 5%
- 457(f) savings plan with employer contribution
- CME reimbursement and paid time off
- Excellent Relocation Assistance packages
QUALIFICATIONS
- EDUCATION - Doctorate
- MAJOR - Medicine
- EXPERIENCE - 5 Years of Experience
- CERTIFICATION/LICENSE/REGISTRATION -
Dr of Osteopathic Med (DO), Medical Doctor (MD): Must have or must
obtain within six months of hire an unrestricted Texas Doctor of
Medicine or a Doctor of Osteopathy license issued by the Texas
Medical Board.
Create a Job Alert for Similar Jobs About Baylor Scott & White
Health Baylor Scott & White Health (BSWH) is the largest
not-for-profit health care system in Texas and one of the largest
in the United States. With a commitment to and a track record of
innovation, collaboration, integrity and compassion for the
patient, BSWH stands to be one of the nation's exemplary health
care organizations. Our mission is to serve all people by providing
personalized health and wellness through exemplary care, education
and research as a Christian ministry of healing. Joining our team
is not just accepting a job, it's accepting a calling! Connections
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Keywords: Direct Jobs, Austin , Medical Director Health Plan, Healthcare , Austin, Texas
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