Medical Director
Albuquerque, NM
 
Oversees all medical care for the health plan's products and services. Oversees the health care needs of the membership and serves as the principal medical manager and policy advisor to the company and health plan CEO or COO. Is accountable for and provides professional leadership and direction to the utilization/cost management and clinical quality management functions. Works collaboratively with other plan functions that interface with medical management such as provider relations, member services, benefits and claims management, etc. Assists in short and long range program planning, total quality management (quality improvement) and external relationships. Works with Corporate Health and Medical Affairs for support, assistance and direction in overall medical management effectiveness. Reports all issues of clinical quality management to the health plan CEO, COO, the Board and the Chief Medical Officer (CMO). Collaborates with the CMO and other health plan medical directors on national medical policies and carries out national medical policies at the health plan in collaboration with the health plan CEO or COO.
 
Primary Responsibilities
Responsible and accountable to the CEO and COO and the Board for managing health plan medical costs and assuring appropriate health care delivery for health plans, products and services. Reports organizationally to the CEO or COO of the Health Plan; has a dotted line relationship to the Corporate Chief Medical Officer.
Plans, organizes, and directs the professional medical services program, consisting of all primary and specialty services for in-patient, out-patient, preventive and wellness programs.
Designs and implements health plan medical policies, goals and objectives.
Provides professional leadership and direction to the functions within the Medical Management Department (Utilization/Cost Management and Clinical Quality Management).
Responsible for and assists with the development of budgets, staffing plans and medical loss ratio projections, assuring the adequate allocation of resources to the medical management functions.
Responsible and accountable for the Utilization/Cost Management Program and Clinical Quality Improvement Program. Performs annual evaluation of these programs and reports findings to the plan CEO, the Quality Management Committee and to Corporate Medical Affairs. Develops annual Utilization/Cost Management and Clinical Quality Improvement work plans based on the annual program evaluation and feedback from peer review committees, QA committee, Corporate Medical Affairs, the CEO and the Board.
Assists the CEO with activities to promote positive community relations.
Assures plan conformance with legal and regulatory requirements. Interacts with regulatory agencies.
Creates and maintains a system that gives feedback to providers individually and collectively regarding managed care effectiveness of individual providers and networks.
Designs and implements corrective action plans to address issues and improve plan and network managed care performance.
Collaborates with Corporate Medical Affairs and the health plan CEO in creating and maintaining programs that incentivize providers to achieve selected utilization/cost and quality outcomes.
Participates in policy review, performs analysis and makes recommendations.
Participates in the retrospective review and analysis of Plan performance from summary data of paid claims, encounters, authorization logs, complaint and grievance logs and other sources.
Achieves and maintains benchmarked utilization and cost management (UM) goals and clinical quality improvement (QI) objectives.
Provides periodic written and verbal reports and updates as required in the Quality Management Program description, the Annual Work Plan and AMERIGROUP Community Care policy and procedures to various plan committees, the health plan CEO and Corporate Medical Affairs.
Supports URAC and NCQA accreditation activities. Prepares for site visits and responds to accrediting and regulatory agency feedback.
Supports pre-admission review, utilization management, and concurrent and retrospective review process.
Participates in risk management, claim adjudication, pharmacy utilization management, catastrophic case review, outreach programs, HEDIS reporting, site visit review coordination, triage, nutrition service review, provider orienta-  tion, credentialing, provider profiling, etc.
Conducts quality improvement and outcomes studies as directed by the state’s Department of Health, the Quality Management Committee, Medical Advisory Committee, Peer Review Committee and management. Reports findings.
Participates in the grievance process, insuring a fair outcome for all members.
Monitors 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.
Establishes and reviews standards for professional and technical staffing ratios for vendors and providers to ensure their ability to deliver medical services to plan members.
Participates actively in provider recruitment.
Assists the contracting process of providers, hospitals, ancillary providers, and emergency and other support services, and evaluates the medical aspects of provider contracts.
Chairs (or delegates leadership of) the Medical Advisory Committees of the health plan which include (but are not limited to) the Peer Review Subcommittee and the Credentialing Subcommittee of the Quality Management Committee.
Participates in key marketing activities and presentations.

Education
Masters in Public Health, MBA or MA preferred.
Continuing education to remain current in medical and management areas.
Any equivalent combination of education and experience.

Required
Five years of clinical experience in the practice of medicine, two of which have been in medical and/or health administration.
Three to five years of management and /or clinical experience in a managed care environment.

Certifications or Licensure
Certified in a recognized medical specialty as recognized by the American Board of Medical Specialist (ABMS).
Must be licensed in the Plan state or District of Columbia as a Doctor of Medicine or Doctor of Osteopathy.
Active license to practice medicine issued by the State Board of Licensure or the State Board of Osteopathic Examiners.
Certification by the American Board of Quality Assurance and Utilization Review Physicians or the American Board of Medical Management desired but not required.