Position Summary
This position is responsible for reviewing authorizations for medical necessity and compliance with HPM utilization management criteria and Michigan Medicaid benefit guidelines.

Essential Functions
Provide supervision of authorization processes in the absence of the Chief Medical Officer.
Develop and implement plans and processes to assure the quality and appropriateness of medical and professional services provided for members of the plan.
Make determinations as to whether medical and pharmacy services are either covered by the member contract or are medically necessary.
Become involved, when needed, in the development of appropriate care standards, drawing on various recognized sources, both locally and nationally, including current literature and the HEDIS standards.
Serve as a resource to respond to high level clinical issues presented by CM staff.
Ensure patient confidentiality in the handling and maintenance of patient data and records, complaints and grievances, and provider files.

Job Requiqements

Education
MD or DO holding current and unrestricted license in the State of Michigan. 
Current board certification in his or her designated specialty.

Experience
Three to five years of relevant clinical management or managed care experience preferred.  Prior Medicaid experience preferred.
Previous experience in quality improvement or utilization management desirable.

Knowledge
Knowledge of managed care particularly with respect to the Michigan Medicaid product preferred.
Knowledge of utilization management processes, including NCQA requirements and time frames preferred.
Quality improvement knowledge preferred.

Skills
Strong organizational and analytical skills.
Computer and internet competence.
Effective negotiation and communication skills.
Skilled at identifying opportunities for process improvement.

Abilities
Ability to prioritize work load effectively.
Ability to communicate effectively with health plan physicians with respect to utilization management decisions
Position Reports To: Chief Medical Officer