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Job Summary

The Medical Director is responsible for contributing professional and technical expertise to the operation of the custom care management program. This includes the clinical aspects involved in the execution of the program and the planning, development and implementation of for program enhancements, membership expansion as well as the development and execution of any future services.

Requirements

EDUCATION

Doctorate Degree in allopathic or osteopathic medicine required.

LICENSING/CERTIFICATION

Holds an active and current unrestricted license pertinent to the role and responsibilities in required jurisdictions. This position operates within the scope that permits them to apply their clinical judgement to render a utilization review determination.

Active and current board certification in area(s) of specialty required.

EXPERIENCE

Minimum ten (10) years' active medical practice preferred.

Minimum five (5) years' clinical leadership experience (role, team and/or project management) preferred.

ESSENTIAL SKILLS & ABILITIES

Proven ability to develop and implement strategic care initiatives.

Ability to work and build relationships across multiple functions.

Skills

• Coaching Others • Consultative Approach • Continued Learning • Cross-Functional Communications • Decision Making • Deductive Reasoning • Employee Engagement Strategies • Evaluating Information • External Collaboration • Inductive Reasoning • Interpersonal Communication • Interpersonal Relationships • Management Techniques • Problem Solving • Process Information • Reading Comprehension • Researching • Service Oriented • Work Schedules • Writing

Responsibilities

• Collaborates closely with the Director of Care Management and Nurse Managers to ensure the effective delivery of custom care management. • Conducts presentations to Enterprise accounts as needed, pertaining to medical management, and provide clinical reporting or analysis as required to support Enterprise account business. • Directs the hiring, coaching/training, employee development and performance management of assigned team.  • Facilitates problem resolution for Enterprise accounts. • Maintains availability for and pro-active in arranging peer-to-peer discussions with providers and facilities nationally and internationally in order to effectively manage appropriate care for Enterprise account members. • Participates in the appeals process at the first or second level in accordance with regulatory requirements and Enterprise account contracts along with organization determination as requested by outside providers. • Participates in the development of primary coverage criterial through selected reviews, presentations, and discussions of the evidence basis for medical science. • Performs other professional duties and responsibilities as assigned. • Possesses or develops and maintains a current in-depth understanding of the evidence-based clinical guidelines and treatments for the medical or behavioral health conditions within their scope and certification to render a clinical opinion or utilization review determination. • Provides consultation to care managers promptly and work with all team members in the custom care management model. • Reviews medical records as required to assist in utilization review activities pertaining the Enterprise. • Works closely with the Corporate Medical Directors, account managers and executives to ensure the smooth running of the accounts. • Works with vendors as needed such as Behavioral Health, Pharmacy, High Tech Radiology, etc.

Certifications

Security Requirements

This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.

Segregation of Duties

Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.

Employment Type

Regular

ADA Requirements

1.1 General Office Worker, Sedentary, Campus Travel - Someone who normally works in an office setting or remotely and routinely travels for work within walking distance of location of primary work assignment.