Medical Director
Columbus, OH

Job Details
Provide medical oversight in appropriateness and medical necessity of healthcare services

Description

Provide medical oversight in appropriateness and medical necessity of healthcare services provided to Plan members, targeting improvements in efficiency and satisfaction for patients and providers, as well as meeting or exceeding productivity standards. Directs and supervises the Quality Improvement Program, Credentialing Activities and Health Education Services:

Interfaces with other departments i.e. Member Services, Provider Services, Claims and Contracting to coordinate operations and programs.
Participate on regulatory, professional and community activities to provide input and become knowledgeable regarding regulatory, professional and community standards and issue
Knowledge of NCQA, QM Multi-specialty group practice and HMO industry. Managed healthcare systems, quality improvement, medical utilization management, and risk management.

Education
Doctorate Degree in Medicine; Board Certified or eligible in a primary care specialty

Utilization/Quality Program Management; Prefer Peer Review, medical policy/procedure development, provider contracting experience

Minimum 5 years clinical practice; Minimum 2 years HMO/Managed Care

Licensure/Certification
An active and unrestrictive Ohio Medical License (free of sanctions from Medicaid or Medicare)
Current Drug Enforcement Agency Certificate

Experience
2 years previous Medical Director