This Corporate-level position provides oversight of the Utilization Management process and assumes responsibilities within the Quality Improvement program.
• Provide clinical leadership for the utilization management process, including authorizations, denials and appeals. Offer clinical guidance to the Utilization Management nurses and other staff.
• Respond to provider inquiries regarding utilization management decisions, complaints and appeals. Promote positive provider relationships.
• Offer clinical insight for the development or adoption of utilization management, pharmacy and quality management programs, as well as medical necessity definition and criteria
• Review post-service appeals and make appropriate determinations regarding the medical necessity and appropriateness of services
• Review practice patterns of physicians and work with the Chief Compliance Officer to identify potential for Fraud Waste and Abuse (FWA) and to report these findings to the Corporate FWA Committee
• Investigate complaints from membership in regard to the quality of care they are receiving and to report these findings to the credentials committee
• Monitor compliance with physician credentialing and re-credentialing policies and procedures. Review “clean” files and prepare exception report prior to Credentialing Committee meeting.
• May serve as the chairperson for the Credentialing Committee and other QI Committees, as delegated by the Chief Medical Officer
• Serves as a member on the Policy Committee, as well as develops policies
• Serves as a contact to meet with providers to review physician Quality and UM issues, as well as data sharing, PIPs, etc.
• Serves as a contact to meet with vendors for possible contract opportunities
• Coordinate with the Chief Medical Officer, the Pharmacy Director and the health plan’s pharmacy benefit manager to ensure appropriate administration of the pharmacy benefit
• Provide clinical oversight and decision making regarding CSHCS applications
• Oversee staff training and education in matters relating to the delivery of medical care, the assurance of quality, and effective control of utilization
• Oversee the care coordination ABAD teams
• Oversee the Transplant team, including evaluation and transplant reviews, policies, data gathering and sharing reporting to MERC/CMO
• Provides oversight and direction for Prolong Length of Stay and Hospital Care Coordination Team
• Provides educational lectures to Care Coordinators, as well as other staff
• Work with the Chief Medical Officer to assure quality of care in all aspects of medical utilization and to assure that health care utilization is appropriate to meet the needs of the members and falls within the recognized standards of efficiency
• Collaborate with MHP Directors to assure MHP compliance with all regulatory programs including National Committee for Quality Assurance (NCQA), URAC or general accreditation and State Medicaid guidelines
• Represent the health plan in the medical community, upon request
• Assist with writing IRO’s and address RFPs/RFIs as needed
• Assist with operational/project management as needed. This includes: community outreach for care coordination teams, previous implementation of project BOOST, PASS, MISTARR, and care transitions
• Perform other duties as assigned
• Current unrestricted license as Doctor of Medicine or Osteopathy is required
• Current board certification in his or her designated specialty is required
• 3 to 5 years experience in managed care and medical management of health plans or in medical programs administration is required
• 5 years Post Graduate experience in direct patient care
• Strong experience in developing and/or implementing practice guidelines is required
• Experience in providing care to a Medicaid population is preferred
• Strong knowledge of utilization management and quality improvement
• Working knowledge of the accreditation standards of the National Committee for Quality Assurance (NCQA) and the Healthcare Effectiveness Data and Information Set (HEDIS)