General Summary

Responsible for clinical leadership, direction and oversight of the health plan's medical affairs including the QAPI Program as well as continuous measuring, monitoring and improvement of the health delivery system for plan members to help ensure that health plan members receive quality, medically necessary care that balances individual need with cost effectiveness. 

Essential Functions and Duties

This position is responsible to provide leadership and oversight for Quality Management activities including credentialing, quality monitoring, physician reporting, and Medical Policy development. Additionally, responsible to provide clinical support expertise for Utilization Management, Case Management and Disease Management. 

Knowledge 
Health care industry, procedures and general business principles
Medical practice

Job Details
The Medical Director will be supporting a growing client base while combining their clinical expertise with payment policy. The MD is a key member of the Research team, as well as the client team and represents the team on all Medical Policy decisions.

The healthcare organization is seeking an innovative physician who is interested in expanding their knowledge outside the practice of clinical medicine, specifically in the areas of medical informatics, health care analytics and disease management.

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

Serves as Medical Director of Care Center.
Responsible for working with call center management and staff to assure high clinical quality programs are delivered to health plan members.
Candidate will lead clinical rounds to address individual patient considerations including level of intervention, provider communications and potential issues.

The Chief Medical Officer is responsible for oversight and management of all of our Washington Health Plan, Healthcare Service Departments.
 
Supervises
Medical Director, Director Quality Improvement, Director Behavioral Health, Director Pharmacy Services, Director Utilization Management, Director Credentialing and Administrative Assistant.
 
Education

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

Description