Position Overview:Actively engage with the provider community in support of PacificSource’s strategic and operational goals. Provide clinical expertise for physical and behavioral health utilization management, as well as health promotion, disease management, pharmacy review, grievance and appeals.
eview pre-authorizations, claims, and other cases involving pre- or post-service requests for coverage.
Conduct other utilization review activities (e.g. lengths of stay, appropriateness of service, intensity of service, medical necessity, and experimental/investigational services) on a prospective, concurrent, or retrospective basis.
Provide expertise and medical interpretation with respect to claims adjudication, underwriting, contract language, disputes and appeals, policy drafts, and care management issues.
Oversee the management of appropriate care and case management related to acute, catastrophic, and long term cases.
Lead the work of employing process improvement techniques to analyze, identify, and implement changes to workflow, staff, and organizational structure that improve operational efficiency and effectiveness.
Review and manage appeals and grievances. Lend expertise to the preparation of cases for appeals, presentation, or further external review.
Assist with credentialing review of providers and the resolution of issues brought forward by credentialing staff. Help to staff the Credentialing Committee, prepare agendas, present practitioner issues, develop policies, and oversee actions of the committee.
Assist the Chief Medical Officer, as requested, including periodic involvement with providers, clients, agents, PacificSource management, board, and other functions or committees as needed.
Coordinate efforts with other PacificSource Medical Directors.
Chair as needed or participate in the Clinical Utilization Management Committee. Prepare agendas, collaborate with the committee, research of topics presented to the committee, and follow through on committee decisions.
Collaborate with all other PacificSource Medical Directors to establish guidelines, policies, criteria and procedures for review and determination related to clinical practices, claims, care coordination, reimbursement, provider credentialing, and quality management.
Assist the Chief Medical Officer or Senior Medical Director as requested, including periodic involvement with providers, clients and agents, PacificSource management, Board, and other functions or committees as needed.
Review Pharmacy denials and redeterminations.
Research new technologies, new medications, and other evolving healthcare products and services to help determine a standard of care and standard of coverage. Assist with drafting and revising policies relating to such issues. Provide visibility and maintain positive physician relationships as a representative of PacificSource in local and regional medical community.
Provide clinical expertise to the Quality Department, including Medicaid Incentive Measures, HEDIS Programs, and Performance Improvement Projects.
Responsible for staff development, coaching, performance reviews, corrective actions, and termination of employees. Provide feedback to direct reports including regular one-on-ones and performance evaluations.
Coordinate business activities by maintaining collaborative partnerships with key departments.
Responsible for process improvement and working with other departments to improve interdepartmental processes. Utilize visual boards and daily huddles to monitor key performance indicators and identify improvement opportunities.
Actively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy.
Work Experience:MD or DO. Three to five years as an Assistant Medical Director or Medical Officer of a health insurance plan strongly preferred. Experience in an integrated healthcare system a plus.
Education, Certificates, Licenses:Unrestricted license to practice medicine by the Oregon State, Montana State, or Idaho State Board of Medical Examiners. Doctor of Medicine degree required.
Knowledge: Comprehensive knowledge of business principles and techniques of administration, organization, and management to include an in-depth understanding of the key business issues that exist in the healthcare industry. These include but are not limited to: knowledge of strategic and operational planning, healthcare economics, personnel administration, federal health reform laws, financial and cost analysis, trends in the healthcare industry, and delivery system transformation including medical home initiatives, business process improvements, analysis and redesign. Excellent verbal and written communication skills, ability to read, analyze and interpret documents, schedules, reports, budgets and correspondence. The ability to develop presentations and reports as well as effectively present information and respond to questions from a variety of groups.Proficient in the use and implementation of the following tools and concepts across all teams within scope of accountability: training, strategy deployment, standard work, visual management, daily improvement, standard follow-up and team development. Strong research, analytical, organizational, and interpretative skills. Excellent understanding of all areas of medical conditions, treatment, and care. Possesses the ability to foresee changes in treatment patterns and implement internal systems as needed. Excellent understanding of the insurance industry and risk factors and how they relate to the PacificSource organization. The ability to identify, create, analyze, and implement innovative cost containment procedures. Excellent negotiating skills. Pro-active in the application of new medical systems and procedures. Expertise in quality assurance and utilization review. Basic computer skills preferred.