Medical Director

Company : Highmark Inc. Job Description : JOB SUMMARY

This jobplays a crucial role in the corporation's success and works closely with all divisions and departments within the corporate structure to provide clinical consultation and support with regard to program development, compliance with accepted medical standards, and practitioner/provider education. The incumbentis an integral part of the utilization management team and assists utilization management staff by direct supervision or as otherwise appropriate to ensure delivery of quality and cost-effective care, member/provider satisfaction, and quality outcomes. A key component of this role is to review denials of care based on medical necessity. The incumbentacts as a liaison for Highmark Wholecare with practitioners/providers through ongoing communications and monitoring of services utilized. As such, the incumbent's role is to provide clinical input into health care management services' activities including for example, care and case management initiatives, clinical program development, and network management. Theseactivities are by nature both line and staff functions. The incumbentassists operations/programs to comply with accreditation and regulatory standards, including but not limited to NCQA, Pennsylvania Department of Health regulations, Department of Public Welfare, CMS, Highmark Wholecare corporate and medical policies. Successful candidate must reside in State of West Virginia

ESSENTIAL RESPONSIBILITIES
•   Communicate effectively.
•   Reviewutilization management cases and communicatethe decisions to the member and provider.
•   Collaboratewith Highmark Wholecare staff and physician advisory committees for development of Highmark Wholecare policies, procedures and special projects.
•   Active participation in establishing Highmark Wholecare's medical policy, and support established policy as it relates to the care management process and communications with practitioners.
•   Become familiar with the principles of continuous quality improvement and apply them in clinical and management functioning.
•   Establish priorities, manage projects in a timely manner, assume responsibilities with limited supervision.
•   Work as a team member coordinating the needs of multiple practitioners and providers across the network.
•   Attend meetings as appropriate, including medical director meetings, QI committee and subcommittees, as assigned.
•   Contribute to the education of other employees by direct consultation and formal presentation in topics of general interest.
•   Serve as a resource for information and consultation on the issues related to utilization management, clinical services and medical affairs, including such issues as case management, disease state management programs and health risk assessments.
•   Assist in the design/implementation of advanced care and case management strategies throughout the network of providers and practitioners to insure efficient care delivery of medical services.
•   Provide consultation to the care and case management staff, offer advice and assistance in achieving resolution of problem cases, and actively support care and case management activities.
•   Intervene as the spokesperson with local practitioners/providers to resolve care and case management issues and participate in the development of long-term strategies to create cost-effective medical care.
•   Assist in the design and development of medical management reports that can be used to identify opportunities for improvement in specific clinical areas.
•   Analyze utilization data and various forms of health care data available within and external to the corporation to evaluate effectiveness of clinical initiatives and care and case management processes.
•   Develop and implement corrective actions.
•   Conduct meetings, seminars, and conferences, and facilitate other forms of group interaction among physicians,in conjunction with other Highmark Wholecare executives and local administration, in order to promote sharing of information expertise, to foster program support, and to enhance identity with Highmark Wholecare.
•   Establish or maintain communication with practitioners and providers and become knowledgeable about their practice patterns in order to identify those factors of quality that define the best practices and once defined, helping them with continuous quality improvement.
•   Meet regularly with physicians and physician groups to represent the corporation in all matters as requested.
•   Become familiar with network issues and how to act as consultant to physicians at hospitals and health care management.
•   Identify specific factors for practices that fall below the standards of quality but have been achieved by the best practices and assist in modification of attitudes and behaviors to assist them in becoming best practices in the care of the patients.
•   Monitor clinical resource allocation, utilization and referral patterns, patient satisfaction, and clinical outcomes across the practitioner and provider network.
•   Develop understanding of current hospital and physician payment methodologies, and how they impact utilization incentives in the provider community.
•   Assist in the design and implementation of education programs for physicians and staff, establish education objectives, and identify resources to deliver educational services.
•   Evaluate physician feedback with regard to capitation, payment performance rewards, pay for performance methodology development and modification, etc. as appropriate.
•   Assist in various corporate initiatives to expand the network, retain practitioners and providers, and complete similar business initiatives.
•   Participate in network promotional activities with members and providers.
•   Seek to become knowledgeable about the regions' physicians, hospitals, and health care environment, and establish working relationships.
•   Establish effective working relationships with hospital, physicians and managers in order to bring about desired outcomes by affecting modifications in the practice patterns for both inpatient and outpatient services.
•   Support clinical program development initiatives through selection of program topics, establishment of criteria, and assisting with vendor selection based on the vendor's proposed approach to clinical management.
•   Monitor the clinical program initiatives in achieving desired quality and financial objectives.
•   Advise the Senior leadership of findings and lead development of corrective action plans as indicated.
•   Attend corporate QI committee meetings and selected subcommittee meetings and report on clinical initiatives and network management activities.
•   Serve as chairperson of the Physician Advisory and Quality Improvement Committees as appropriate, to provide oversight and direction to the quality improvement activities of the corporation.
•   Develop a working knowledge of the credentialing process and criteria and participate in education and sanctioning activities directed at individual network physicians.
•   Work with the credential staff to review provider applicants and to make decisions regarding approval, denial, and/or terminations according to Highmark Wholecare's policies and NCQA standards.
•   Become familiar with corporate credentialing policy, and assist in its design.
•   Become familiar with the principles of the TQM/CQI processes.
•   Seek to teach them and apply them in network medical functioning.
•   Regionally supervise and/or collaborate the activities/directives of the QI operations staff and committees.
•   Attend corporate QI committee meetings, and report on regional actions related to committee function.
•   Closely collaborate with the regional quality staffs to ensure maximum effectiveness within the organization.
•   Organizational providers - Assist in the evaluation and credentialing of organizational providers, including hospitals, home health agencies, SNFs, etc. Work closely with them to assure ongoing relationships with the corporation maximize their effectiveness.
•   Grievances and Appeals - Assist in the evaluation and resolution of grievances and appeals of patients, providers, and hospitals.
•   Maintain familiarity with applicable State and Federal Quality Assurance Regulations to ensure the organization's compliance with them.
•   Develop expertise in the external requirements for quality leadership, including NCQA accreditation, and the creation of an accurate HEDIS data set.
•   Assist in the development of internal physician advisors and provide support in developing solutions for complex cases, in the authorization and denial of services, and in the grievance and appeals process.
•   Assist in monitoring effectiveness of physician advisors in supporting the care and case management activities.
•   Assist operation staff in the clinical oversight of subcontracted services and other organizations for which Highmark Wholecare is liable for quality oversight
•   Effectively interact with professional groups, such as state and county medical societies, hospital executive committees, medical staff executive committees, payers, member related associations, community groups etc.
•   Participate in presentation of corporate goals and interests to practitioners/providers, community and business groups, social agencies, and government bodies click apply for full job details