Medical Director (MD) - Non- Profit Member Governed Health Insurer
- Position Type
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.
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:
- Member of the Executive Staff and participates in Executive meetings and quarterly board meetings.
- Participates in care management activities with the third-party administrator’s (TPA) medical director and staff, and shared management of one site nurses.
- Participates in the TPA’s Pharmacy and Therapeutics Committee.
- Monitors standardized metrics including medical and pharmacy cost and utilization by state, product, network, and perform analysis and identify opportunities to reduce cost.
- 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.
- 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).
- Works collaboratively with risk-sharing networks, to assure mutual success.
- Monitors member appeals and participates in the committee for final determination.
- 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.
- Participates to assure consistent member contract language, and identify opportunities for preauthorization, limitations, exclusions etc.
- Determines when external review of an appeal is appropriate.
- Actively participates in risk-score management activities.
- Works with management and staff members to improve organizational efficiency, resolve issues, coordinate activities, etc.
- 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
Apply for Medical Director (MD) - Non- Profit Member Governed Health Insurer
Already uploaded your resume? Sign in to apply instantly