Job Description
Job Description: Provides strategic leadership and clinical oversight for all medical directors and supports the development and implementation of medical policies and care management programs. Acts at the primary clinical advisor across medical and behavioral health operations, with a focus on quality improvement, policy development and regulatory compliance. Ensures evidence-based standards guide all utilization and appeal review activities and represents the organizations in key clinical committees and provider engagements.
Responsibilities: - Formulate and recommend policies relating to covered services, quality assessment and provider oversight.
- Receive, communicate and interpret policies of the governing body to direct reports, ensuring dissemination to the appropriate staff.
- Work closely with the Chief Executive Officer and Clinical Operations Officer on matters related to interdepartmental coordination within the clinical aspects of the company.
- Serve as the plan's principle liaison and represent the plan in meetings with providers to facilitate collaborative efforts to improve patient care.
- Serve on various committees, task forces and special project teams of the plan.
- Provide leadership and management to ensure effectiveness of medical policies by maintaining ongoing evaluation of the provider communities' quality of care and managed care educational needs.
- Participate in the interview and hiring process for key clinical staff positions, including but not limited to, all nursing leadership positions and all medical directors.
- Devote approximately 50 percent of time to quality-related activities.
- Present and interpret utilization data both internally and externally.
- Develop and manage medical policies and procedures and ensure compliance with them.
- Advise and assist the networks and physicians in ensuring the effectiveness of programs and meetings.
- Work closely with health systems to align policies and goals to improve quality and increase efficiency.
- Ensure the organization has qualified clinicians accountable for decisions affecting consumers.
- Remain available for real-time consultation and to be a resource for the nurse reviewers' determinations.
- Render determinations on medical or drug utilization management cases under appeal.
- Ensure compliance with federal and state laws, regulations and standards of regulatory or certifying organizations.
- Implement sanctions where indicated by regulatory or accrediting bodies.
- Performs other duties as assigned.
Requirements: - Demonstrated leadership abilities within large and complex healthcare organizations
- Well-developed interpersonal skills with the ability to interpret complex information from a variety of sources
- Creative, energetic individual with strong public relations abilities
- Professional demeanor with a positive attitude and self-motivation
- Previous experience in discharge planning, care coordination or case-management
- Experience working with complex data, including management, reporting, visualization and communication
- Successful completion of healthcare sanctions background check
- Ability to speak and write fluently in English
- Graduation from an accredited medical school
- Residency trained in medical discipline
- 5+ years of experience in post residency clinical practice
- 10+ years of experience as a health plan medical director or Chief Medical Officer
- Current, active, unrestricted license to practice medicine in Oklahoma
- Board certified; certification must be maintained
- Additional management training strongly recommended – master's degree in a related field (preferred)
- License must be of type and scope that permits clinical judgment in utilization review determinations
- Must be licensed as either a Doctor of Medicine or Doctor of Osteopathic Medicine
Contact:
Sal Monteleone
smonteleone@jacobsononline.com
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