Medical Director (MD) - Non- Profit Member Governed Health Insurer

Employer
Healthcare Executive Connections
Location
Bozeman, Montana
Posted
Jan 11, 2019
Closes
Jan 11, 2020
Ref
1947252
Specialty
General Practice
Hours
Full Time
Position Type
Permanent
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Mission: Offer non-profit, member-governed health insurance that promotes member engagement and provides access to high quality medical care.

Vision: Champion a more innovative, member-centric healthcare delivery system by promoting the triple aim where providers are engaged to improve population health, improve individual healthcare, and control healthcare spending.

Core Values:

Customer focus - Communication - Quality - Integrity - Responsibility - Respect - Credibility - Innovation – Teamwork- Wellness

Medical Director’s role; Alignment with Health Cooperative’s  Mission, Vision and Values:

DUTIES AND RESPONSIBILITIES:

  1. Member of the Executive Staff and participates in Executive meetings and quarterly board meetings.
  2. Participates in care management activities with the third-party administrator’s (TPA) medical director and staff, and shared management of one site nurses.
  3. Participates in the TPA’s Pharmacy and Therapeutics Committee.
  4. Monitors standardized metrics including medical and pharmacy cost and utilization by state, product, network, and perform analysis and identify opportunities to reduce cost.
  5. Works collaboratively with Provider Contracting to facilitate improved contractual agreements to ensure quality and lower cost, such as alternative payment methodologies, fee schedules, and prospective payment.
  6. Acts as the senior physician with oversite of the Quality Committee and participates in the development of cost-effective quality improvement and assures regulatory compliance to maintain accreditation certification as a Qualified Health Plan, (QHP).
  7. Works collaboratively with risk-sharing networks, to assure mutual success.
  8. Monitors member appeals and participates in the committee for final determination.
  9. Performs selective high dollar chart and bill review to identify processing errors, fraud, or abuse and identify opportunities for improved contracting or future member contract and benefit change.
  10. Participates to assure consistent member contract language, and identify opportunities for preauthorization, limitations, exclusions etc.
  11. Determines when external review of an appeal is appropriate.
  12. Actively participates in risk-score management activities.
  13. Works with management and staff members to improve organizational efficiency, resolve issues, coordinate activities, etc.
  14. Direct, plan and implement necessary policies and objectives which may include budget preparation and oversight.

EXPERIENCE & QUALIFICATIONS:

  • MD, DO, with board certification in any specialty
  • 10 years of experience in a managed care setting
  • Experienced/solid understanding of health plan insurance policies, benefits & interpretation
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