The Medical Director provides oversight of a comprehensive medical policy implementation and utilization management services. The Medical Director develops and sustains an interface with member forums and facilitates the delivery of appropriate care. . The Medical Director contributes to the development of the clinical mission of the CMC, including the development, implementation, and evaluation of clinical/medical programs.

Essential Functions

Senior Medical Reviewer: Direct the utilization review process and oversee the quality of utilization determinations.  Responsible for the quality of the utilization review determinations made in the CMC. Develop and implement a utilization management program and action plan; Ensure compliance with clinical goals through regular monitoring of care management center performance. Evaluate the effectiveness of the clinical program and modify programs as need to achieve desired results.

Provide medical leadership, oversight, and consultation for Quality Improvement Program, and Utilization Management Program including: monitoring effectiveness and compliance with goals, prevention programs, network development and management, quality of care concerns and adverse incidents, medical practice of network or sub-capitated providers, clinical service delivery system.; coordination with After Hours Team and appeals -panel physicians, oversight of clinical appeals. The Medical Director works collaboratively with QI on the development and implementation of QI activities, UM and QI program descriptions, evaluations, and work plans.

Develop, implement and interpret medical policy for the Care Management Center (including Medical Necessity Criteria, Clinical Practice Guidelines and New Technology Assessments).

Recruit, train, supervise, mentor, oversee, and evaluate the quality of medical staff and physician advisors utilized by the CMC. Ensure that the CMC has adequate physician advisor resources. Develop and manage the physician advisor budget.

Minimum Requirements

Education
Graduate of an American or Canadian medical school accredited by the Accreditation Council for Medical Education (ACME) or equivalent training in a foreign medical school with successful completion of the ECFMG and FLEX examinations. Full training in a residency program in the United States or Canada that is approved by the ACGME.

Experience
5-8 years Post-residency experience of at least 5 years involving substantial direct patient care during this period at multiple levels of care. Clinical experience pertinent to the patient population(s) being managed.

Licenses, Certifications
Must have current active license to practice medicine in the U.S. Licensed or licensure eligibility in state of operation. Licensure must be complete within the 1st year of employment . Board certification by the American Board of Psychiatry and Neurology.

Other
Familiarity with current research and use of psychopharmacologic and psychotherapeutic modalities of treatment.

Preferred Qualifications

Experience
Managed care experience preferred, as provider and manager of care. Utilization Review experience preferred. Accreditation experience (NCQA, AAHCC/URAC) preferred.