Job Description

JOB SUMMARY

A duly licensed doctor of medicine or doctor of osteopathic medicine responsible for clinical oversight of the utilization management program. Functions include training of new clinical staff, professional staff, physician advisors, quality management and improvement, and training and development, as well as participating in customer meetings and quality committee meetings. This is a leadership opportunity to provide governance to physician reviewers, as well as, ongoing training and quality oversight.

**This is a contract position**

MAJOR DUTIES & RESPONSIBILITIES

• Perform quality assurance training and audits on new physician reviewers ongoing training and audits of current panel physician reviewers.
• Serve as the clinical lead for the Group Health Department. The Associate Medical Director must be easily accessible to clients, physician advisors, client medical directors and clinical and non-clinical staff.
• Assist the Group Health Department with quality assurance of reports prior to submission to clients. Manage and train new physician advisors and existing panel physicians as necessary in the remediation process to ensure timely and accurate medical record files and summaries.
• Perform random case audits in accordance with company policy or client specifications. Perform case audits for newly credentialed physician advisors, as well as, random cases from veteran physician advisors, in accordance with policy IRO-09, Performance Monitoring.
• Serve as clinical lead for all URAC accreditations. Work closely with the Chair of the Quality Management and Credentialing Committee (QMC). Must attend at least three QMC meetings per year in person or by phone. Must be available to facilitate QMC meetings in the Chair’s absence.
• Respond according to Credentialing Committee requests, In addition, be familiar with guideline use and clinical criteria if applicable and national or regional medical treatment guidelines forr group health utilization Management reviews.
• Work directly with the credentialing team in overseeing the credentialing of physician advisors.
• The Medical Director must be easily accessible to the company’s clinical and non-clinical staff. Must be available at least 20 hours per week during normal business hours.

EDUCATION/CREDENTIALS:

Board Certified M.D. or D.O. with current, unrestricted clinical license in any State in the U.S.

JOB RELEVANT EXPERIENCE:

Minimum five years postgraduate experience. Extensive clinical business background required. Experience working in Utilization Management with criteria review utilizing standard practice guidelines.

JOB RELATED SKILLS/COMPETENCIES:

Working knowledge of URAC and relevant State and Federal compliance guidelines. Excellent communication skills, high level understanding of medical insurance and utilization management, critical thinking, ability to manage time efficiently and to meet specific deadlines. Computer literacy and typing skills required.

WORKING CONDITIONS/PHYSICAL DEMANDS:

Any lifting, bending, traveling, etc. that are required to do the job duties listed above. Long periods of sitting and computer work.

WORK FROM HOME TECHNICAL REQUIREMENTS:

Supply and support their own internet services.

Maintaining an uninterrupted internet connection is a requirement of all work from home position.

This job description is subject to change at any time.

PLEASE BE AWARE: In the interest of the security of both parties, please be aware that Dane Street will never conduct an interview via text or request checks from candidates for purchasing equipment.

Job Tags

Similar Jobs