Bishop & Co. is seeking qualified candidates for a Medical Director opportunity for a well-established Medicaid and Medicare Health Plan Organization based in Honolulu, HI.
Are you a licensed Medical Doctor (MD/DO) seeking an opportunity to utilize your skills and experience in healthcare, serving Medicaid and Medicare beneficiaries through a locally managed health care plan in Hawaii?
Do you have a passion for providing outstanding quality of care and safety and championing quality improvement to improve the overall health of the population served?
If your passion includes building relationships among health care providers, social services, and public agencies, then this is the job opportunity for you!
The Medical Director is a key member of the health services team that strives for outstanding member quality of care and safety, supporting quality improvement, proper utilization of health service benefits under MedQUEST and Medicare, implementation of the Care Model with its risk-stratified care coordination, achievement of Medical Loss Ratio initiatives, completion of regulatory compliance, and fulfillment of NCQA standards. Responsible to build external relationships that strengthen the provider network, while serving as a contributor of operational and strategic planning. Reports to the Chief Medical Officer.
Primary Duties and Responsibilities:
- Quality Improvement: Oversees the Department of Quality Improvement, providing medical direction to the department Director in programs, such as the following:
- Pay-For-Performance for providers
- MedQUEST quality incentive program for health plans
- Stars Rating
- Performance Improvement Projects (PIPs)
- Behavioral Health quality projects
- Utilization Management: Collaborates with the Manager, Utilization Management, in daily medical oversight related to prior authorizations.
- Participates in coverage determination of prior authorization requests based on medical necessity;
- Contributes solutions to reduce the administrative burden of prior authorizations on providers.
- Participates in making final determinations of complex or problematic prior authorization requests that may involve interdisciplinary discussion, independent review organization, and online sources of evidence-based diagnostics or treatments.
- Assists in overseeing the development and maintenance of medical policies that state the guidelines and criteria for medical necessity.
- Collaborates with pharmacists in addressing issues involving under/over utilization, drug prior authorizations, medication adherence, provider services, and safety.
- Develops and maintains skill in using web-based tools for medical decision- making and actionable analytics.
- Assists in the processing of ADRC (Aid to Disabled Review Committee) submissions to MedQUEST for added benefits under the Aged Blind and Disabled program.
- Actively contributes to Medical Loss Ratio initiatives related to high utilizing, clinically complex members as well as preventing hospitalization or avoidable emergency department visits.
- Takes part in NCQA Accreditation implementation of standards.
- Participates in MedQUEST and Medicare audits and follow-up, as assigned.
- Attends regular or ad hoc meetings, such as Interdisciplinary Team conferences, concurrent review rounds, wait list rounds, transfers to mainland centers of excellence.
- Interacts with the Provider Community – such as hospitals, emergency departments, skilled nursing facilities, long term care institutions, group, or solo providers – building relationships, identifying opportunities, and educating providers about the organization’s services and understanding their respective needs for health plan support.
- Develops and nurtures relationships with community health centers (Federally Qualified Health Centers), independent providers, and institution-based medical leaders.
- Participates in strategic planning that involves health services, provider network development, and support of providers.
- Assists in scheduling medical director coverage, as well as participating in the on-call schedule on weekends and holidays.
- Participates in disaster planning, drills, and response.
- Board Certified Doctor of Medicine or Osteopathy (MD/DO) REQUIRED
- Five or more years of clinical practice in direct patient care
- Experience in medical leadership of clinical services, programs, or provider organizations
- Three or more years of health plan and/or provider systems experience
- Strong communication skills and emotional intelligence
- Previous experience as a Medical Director
- Experience in a managed care organization
- State of Hawaii unrestricted licensure to practice medicine
- Active/Current Board Certification in excellent standing
** OUT OF STATE CANDIDATES: **
Please outline your professional and/or personal ties to Hawaii in your application/resume/cover letter and/or communication. Required
Bishop & Company provides recruiting and placement services for client companies and opportunities for job seekers throughout Hawaii, with emphasis on executive search, direct hire, temp to hire, and temporary/contract staffing. We charge no fees to our placed candidates and our temporary/contract employees. Our client services are 100% guaranteed.
Please forward resumes to:
Bishop & Company
***Equal Opportunity Employer – Disability and Veteran