- Position Type
As a Medical Director at Premera, you will lead activities for Government Programs. The Medical Director is responsible for the activities of Premera and its affiliates that support collaborative relationships with providers and effectively communicates the value of Premera's Quality and Utilization Management activities to customers. The Medical Director develops and implements strategic plans that are consistent with Integrated Health Management (IHM) initiatives and works collaboratively with internal and external partners to achieve the business goals of Premera and its affiliates. The incumbent works closely with leaders across the organization.
What you will do:
- Provide leadership and clinical oversight of one or more of the following areas in IHM to support compliance and innovation:
a. Medical policy administration and review
b. HEDIS and NCQA quality
c. Product and sales consultation and partnership
d. Provider network support
- Consult with internal partners on the application of clinical practices and Government programs that support corporate programs and corporate/department initiatives.
- Partner with stakeholders across the organization by providing expertise on medical cost management, best practices in quality, medical trends and the application of evidence based medicine decision making.
- Consult with external providers or employer groups on all Government programs, products, services and initiatives.
- As assigned, implement all medical decision-making policies and review criteria while ensuring consistency of application.
- Support member appeals and provider appeals processes and staff.
- Manage assigned projects. May be responsible for managing a team of associates to meet the evolving needs of the organization.
What you will bring:
- MD/DO degree.
- Five years' experience in clinical practice.
- A Current, unrestricted medical or administrative license in the state assigned or obtain an unrestricted medical or administrative license in the assigned state.
- Current board certification from the American Board of Medical Specialties, or the American Osteopathic Association or other recognized Association acceptable to Premera.
- Experience in a managed care environment - either with a health plan or medical group - including experience in utilization management.
Preferred Qualifications: (please note those which are preferred for this role)
1. MBA, MHA MPH or other related master's degree.
2. Experience with health plan accreditation, e.g. URAC or NCQA.
3. Experience with Disease Management.
4. Experience with Quality Management.
5. Experience with Pharmacy Management.
6. Knowledge of data management and information systems.
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