The Health Plan Medical Director is responsible for managing health plan medical costs and assuring appropriate health care delivery for plans and members. Is accountable to provide professional leadership and direction in the utilization/cost management (UM) and clinical quality improvement (QI) of the health plan, as measured by benchmarked UM and QI goals. Works collaboratively as a clinical resource to other plan functions that interface with medical management such as provider relations, member services, benefits, claims management, etc. Carries out medical policies at the health plan consistent with NCQA and other regulatory bodies.
WHAT IS EXPECTED (Essential Functions): • Identify opportunities for corrective action plans to address issues and improve plan and network managed care performance.
• Collaborate with Provider Networks and Medical Director team in creating and maintaining programs that incentivize providers to achieve selected utilization/cost and quality outcomes.
• Participate in the retrospective review and analysis of Plan performance from summary data of paid claims, encounters, authorization logs, compliant and grievance logs, and other sources.
• Provide periodic written and verbal reports and updates as required in the Quality Management Program description, the Annual QI Work Plan.
• Assure plan conformance with legal and regulatory requirements; support NCQA qualification activities, including site visits and response to accrediting and regulatory agency feedback.
• Support pre-admission review, utilization management, concurrent and retrospective review process and case management.
• Participate in risk management, claims administration, pharmacy utilization management, catastrophic case review, outreach programs, HEDIS reporting, site visit review coordination, triage, nutrition service review, provider orientation, credentialing, profiling, etc.
• Conduct quality improvement and outcomes studies as directed by the state and federal regulatory agencies, the Quality Management Committee, Medical Advisory Committee, Peer Review Committee, and management.
• Support grievance process, as led by Chief Medical Offices, insuring a fair outcome for all members.
• Monitor member and provider satisfaction survey results and implements changes as needed to increase satisfaction and assure that satisfactory relationships are maintained between network and plan participants.
• May be asked to chair various Health Plan committees, such as Quality Management subcommittees on Peer Review or Credentialing.
• Promote wellness and ensure programs of prevention, education and outreach to members and providers consistent with company's mission, vision, and values.
• Perform and oversees in-service staff training and education of professional staff.
• Contribute to the development of strategic planning for existing and expanding business;
• Recommend changes in program content in concurrence with changing markets and technologies.
• Participate in key marketing activities and presentations, as necessary, to assist the marketing effort.
• Performs other position appropriate duties as required in a competent, professional, and courteous manner as directed by management.
MINIMUM REQUIREMENTS: •Doctorate Degree Required •5+ years of experience •Unrestricted License Texas as a Doctor of Medicine or a Doctor of Osteopathy. •Certified in a recognized medical specialty as recognized by the American Board of Medical Specialists (ABMS).
For confidential consideration please contact:
Rose Coker Executive Recruiter Rose.Coker@bswhealth.org (214) 785-5956
Some have jobs. We have a calling.
Baylor Scott & White Health (BSWH) is the largest not-for-profit health care system in Texas and one of the largest in the United States. With a commitment to and a track record of innovation, collaboration, integrity and compassion for the patient, BSWH stands to be one of the nation’s exemplary health care organizations. Our mission is to serve all people by... providing personalized health and wellness through exemplary care, education and research as a Christian ministry of healing. Joining our team is not just accepting a job, it’s accepting a calling!