Value Based, consumer driven, accredited CO- OP seeks experienced medical director to lead medical management, quality and customer engagement to continue the insurer's success covering 50k members with accessible, high quality care in Idaho and Montana.
Responsibilities include :
Provider relations, shared reimbursement contractiing and risk contract management, network development, utilization review, second level appeals, pharmacy benefit management.
Quality improvement program lead chairing committee, monitoring utilization and data and developing innovative wellness and chronic care management programs to maintain and improve compliance in seeking appropriate care to improve overall health and lower overall costs, in-patient stays and sentinal events.
Partner with TPA medical director and staff and onsite nurse managers to efficiently serve members and physicians/offices with access to timely appointments, eligibility, utilization review, pre-authorizations, claims and benefit questions and concerns.
Research and analyze data to provide feedback to physicians to maintain mutual success in risk sharing, communication of policy updates and to ensure compliance with regulatory requirements.
Continue to maintain all requirements for accreditation as a Qualified Health Plan.
M.D. or D.O.
Board certified in medical specialty
License to practice medicine or review utilization required.
10 years of managed care experience with involvement in medical and quality management, medical policy, benefit & claims review, provider relations and contracting, utilization and pharmacy benefit management, data analysis, program development and project management expertise
Additional Salary Information: Competitive salary and bonus
Internal Number: 313
About c/o Healthcare Executive Connections
National health care executive search, partnering with managed care and population health focused clients and vendors with expertise in government programs, patient centered models, ACA, behavioral and pharmacy benefits management, e-Health solution, and integrated and post-acute care delivery.
Specialize in Medicaid, Medicare products and organizations supporting patient centered medical home, affordable and integrative care for population health and wellness.