OH, FL, IL, MO, AZ

The Medical Director will assist the Chief Medical Officer to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit.

• Provides medical leadership for Medicare utilization management activities, Organizational Determinations, and medical review activities pertaining to utilization review, quality assurance, medical review of complex, and controversial or experimental medical services such as transplants utilizing the services of consultants
• Performs case reviews and appeals for all health plans
• Facilitates Grand Rounds and case reviews with other clinicians and external treating providers
• Participates as an active member of the Integrated Care team (ICT)
• In collaboration with the VP of Clinical Programs, develops clinical programs and approaches targeted
to improve health outcomes for complex care and high acuity populations
• Assists VP of Clinical Programs in planning, establishing goals and policies to improve quality and cost-effectiveness of care and service for members.
• Provides medical expertise in the operation of approved quality improvement and utilization
management programs in accordance with regulatory, state, corporate, and accreditation
requirements.
• Identifies utilization review studies and evaluates adverse trends in utilization of medical services,
unusual provider practice patterns, and adequacy of benefit/payment components.
• Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical
practice in order to improve the quality and cost of care.
• Reviews claims involving complex, controversial, or unusual or new services in order to determine
medical necessity and appropriate payment

Requirements
• Must be an actively practicing physician or willing to practice 4 hrs/wk
• MD or DO from an accredited medical school
• Board certification in psychiatry by the Board of Psychiatry and Neurology
• Experience treating or managing care for a culturally diverse population preferred
• Previous experience within a managed care organization required
• Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel
Management preferred

Apply Now

Not sure if you want to apply?
Contact us for more info:
Rebecka Boyd
804-502-0870
nexusexecutivesearch@gmail.com