The Medical Director works collaboratively with our internal stakeholders, providers and external customers.  This person has the opportunity to integrate medical expertise while working with representatives from all areas of the business for the purpose of managing medical benefit costs and maintaining positive customer and provider relations.

The Medical Director, Care Management Focus will assume accountability for support of the care management function of the health plan.  This entails primary accountability for all utilization review activity as well as support for network economics (reimbursement/coding policy), pharmacy strategy and policy support (Medical Technology, Utilization Management, and Reimbursement).  Other areas of accountability will include support for the Special Investigations Unit, underwriting, as well as support for sales and marketing.  The medical director will become the organization's expert in utilization management and care management strategy and execution.

Performance Objectives:
 
Review and become familiar with our customers - During the first 30 days meet with sales and marketing to gain an understanding of our customers including, but not limited to, our largest employer groups, key clients, Federal Employee Program, First Administrators and other customers of importance.  Gain an understanding of the salient details concerning our key accounts with an emphasis on care management and our value proposition. Within the first 60 days, participate in meetings concerning key accounts and offer support and assistance to sales and marketing where required.
 
Demand (Care) Management - Gain familiarity with all aspects of care management including utilization management, case management, disease management and pharmacy management.  Become familiar with the medical director role in these processes and achieve readiness to participate in active case review and decision making.
 
Care Improvement (Quality) - Become familiar with our quality program, history of the program and future direction.  Understand the components (suites) of the program and achieve readiness to discuss the program with providers.  Gain familiarity with the health plan's direction concerning reimbursement pilots and innovative strategies to work collaboratively with physician groups to improve care.

Network Engagement - Gain familiarity with the physician and hospital groups in Iowa and South Dakota and the relevant strategic relationships.  Meet with Network Engagement to gain understanding of their provider support processes and the role of the medical director in supporting the network.
 
Policy Management - Gain an understanding of the technology assessment process of the health plan and its relationship to care management and network economics.  Gain familiarity with the different policy types and the role of policy in support of the certificate of coverage.
 
Network Economics/Claims Payment - Become familiar with the process for claims payment at the health plan including professional, outpatient facility and inpatient facility payment strategies.  Gain a working understanding of reimbursement policy/code edits and the role of the medical director in oversight and management of this area.
 
Special Investigations - Meet with the Special Investigations unit staff to gain an understanding of the scope of fraud and abuse investigations.  Learn the medical director role in fraud and abuse cases.  Familiarize one 's self with the active cases to develop readiness to assume case review by 3 months.
 
Pharmacy Management - Within 30 days, meet the health plan's pharmacy team as well as key individuals from the pharmacy benefits manager.  Develop an understanding of the formulary process, utilization management process, and specialty pharmacy management process.  Develop readiness to chair the Pharmacy and Therapeutics Committee in 90 days or after observing one meeting, whichever comes first.