Job Description
Job Description
Onsite / Not a Remote Position
Position Purpose : Responsible for the overall management of the medical division including medical management, case management, utilization management and all other division functions.
Responsibilities :
- Identification of utilization patterns to evaluates trends in inpatient and outpatient utilization.
- Identifies and evaluates unusual provider practice patterns.
- Monitors adequacy of benefit / payment components.
- Work collaboratively with quality improvement, member services, medical care management, provider relations and the executive team to improve quality of care and outcomes.
- Participates in the review and assessment of complex and / or unique claims.
- Solicit and evaluate advice of outside medical consultants and physicians with respect to complex or experimental procedures.
- Provides medical expertise with respect to planning and establishing goals and objectives to improve medical care management and outcomes.
- Participates in provider network development and new market expansion as appropriate.
- Participates in the review, assessment and negotiation of provider contracts as needed.
- Interfaces with the provider community regarding medical care management, utilization review and quality improvement issues and concerns.
- Performs other related duties as indicated by the President / CEO and / or the Board of Directors.
Qualifications :
- Medical degree from an accredited University.
- Board eligible or certification in primary care.
- Minimum of 5 years experience in managed care.
- Experience in the development and management of utilization review and quality improvement programs.
- Outstanding oral and written communication skills.
- Excellent leadership skills and the ability to motivate through a proactive management style.
Note : This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s).
Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.
No Third Party Agencies or Submissions Will Be Accepted.
Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. DFWP
Opportunities posted here do not create any implied or express employment contract between you and our company / our clients and can be changed at our discretion and / or the discretion of our clients.
Any and all information may change without notice. We reserve the right to solely determine applicant suitability. By your submission you agree to all terms herein.
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