Position Summary

Provides professional leadership/direction and support to Medicare, Sales and Account Management for Managed Medicaid, Utilization Management, Pharma Services, and Provider relations.

Provides physician leadership and direction to the Medicare Fraud, Waste and Abuse activities, including review of outlier cases. Presents clinical evaluation to designated Medicare oversight body to meet corporate requirements for accuracy and message consistency. Provides physician support for Med D activities as delegated by the Medicare Medical Director, including appeal and formulary exception evaluations where an MD is required.

Provides primary Physician support for commercial Lines of Business UM (PA/Appeals) reviews where internal MD is required by contract or accreditation standards, including oversight of external UM vendors.

Primary contact for provider relations/support, responding to highly escalated physician calls from service recovery unit where medical director availability is required.

Provides physician review of clinical content of clinical programs and communications, including Pharma Services physician and participant communications and consumer web site materials.

Acts as physician dedicated to provide sales and account management support for identified key clients as required by the business, including Managed Medicaid. Periodic on site visits with client clinical team required.

Provides physician support of specific cross functional projects, including specialty.

Qualifications

Graduate of an accredited US Medical School and Residency program. Board Certified in an ABMS specialty, preferably primary care. Must possess unrestricted active medical license. ABQAURP certification and MBA preferred.

Education

MD (medical degree) from an accredited US medical school is required.

Experience

7 plus years of relevant experience. Minimum of five years clinical experience in the practice of medicine. Three to five years minimum of managed care management experience. Experience with Utilization Management activities, clinical outcomes, statistics, and regulatory/accreditation standards. Public speaking skills required. Must have demonstrated ability to work well in cross functional teams.