Medical Director – Health Plan

This is a fully remote position, open to applicants in Alabama, +31 more states.

📋 Description

• Provides professional leadership and guidance in utilization and cost management as well as clinical quality management functions within Martin’s Point Health Plans.

• Collaborates effectively with Health Management, Quality, Network Management, Member Services, benefits and claims management, and Compliance departments.

• Aids in both short- and long-term program planning, quality management, and fostering external relationships.

• Acts as a crucial implementer of the Health Plan’s Triple Aim strategy, focusing on the cost management aspect.

• Assists in managing the medical costs of the health plan by ensuring the delivery of clinically appropriate healthcare for health plan products and services.

• Conducts medical necessity reviews for requests related to health plan-covered services.

• Reviews disputes and appeals to assess clinical appropriateness.

• Participates in case reviews to guarantee the quality and safety of care and services provided to members.

• Aids in developing annual Utilization Management, Care Management, and Disease Management Program Descriptions while ensuring compliance with accreditation and regulatory standards, including NCQA, CMS, and TRICARE.

• Engages in medical policy review and the development of policies.

• Collaborates with Informatics, Network Management, and Medical Economics to evaluate network providers concerning cost management and formulates communication plans for outliers.

• Cultivates a comprehensive understanding of ACOs and contributes to their management and strategic implementation.

• Provides necessary support for Health Plan risk adjustment activities.

• Leverages knowledge of Health Plan goals and strategic initiatives, including utilization and cost management, MLR, inpatient days per 1000, SNF days per 1000, and HEDIS-related clinical quality improvement objectives.

• Reports to the VP Medical Director and collaborates closely with other Health Plan leaders.

⛳️ Requirements

• MD/DO degree.

• Active and unrestricted medical license in Maine or New Hampshire; or eligibility to apply for and obtain licensure in another U.S. state.

• Board certification as a physician.

• Required post-graduate experience in direct patient care.

• Preferred 2-5 years of experience in utilization management within a health plan environment.

• Familiarity with process improvement tools.

• Extensive knowledge and practical insight into healthcare systems and managed care concepts.

• Strong commitment to performance-based Health Plan systems.

• Good analytical skills with the capacity to identify significant trends and improvement targets.

• Exceptional interpersonal skills with a proven ability to build rapport and maintain working relationships with providers, service vendors, and internal staff.

• Demonstrated capability to manage and develop staff.

• Openness to exploring innovative approaches to medical management.

• This position is not eligible for immigration sponsorship.

🏝️ Benefits

• Medical insurance.

• Dental insurance.

• Vision insurance.

• Retirement savings with employer contributions.

• Paid time off.

• Volunteer time off.

• Pie day.

• Additional employee benefits.

• Additional compensation opportunities, including incentive or commission-based programs, where applicable.