National Medical Director Utilization Management - Quality Management

Company: Hybridge Staffing
Location: Las Vegas
Posted on: January 24, 2023

Job Description:

Medical Director opening in Las Vegas, Nevada. This and other physician jobs brought to you by DocCafe

National Medical Director Utilization Management – Quality Management

*Employed
*Can work remote
*Growing organization
*Excellent compensation package and full benefits
Job Description:

• 
  
• Leads, develops, directs, and implements clinical and non-clinical activities that impact health care quality cost and outcomes.
  
• Identifies and develops opportunities for innovation to increase effectiveness and quality.
  
• Provide clinical expertise across the enterprise for various functions.
  
• Responsible for corporate and medical policy interpretation, recommendation, and review within recognized areas of responsibility.
  
• Advise and collaborate in the develop of clinical programs.
  
• Provide clinical support and participate in utilization management, quality management and care management programs in respective area and identify opportunities for improvement and efficiency.
  
• Assist with the design, development, implementation and assessment of preventative care, quality, and health enhancement programs that support the appropriate use of clinical resources in the delivery of consistent high- quality medical care to drive HEDIS metric compliance.
  
• Provide clinical leadership for medical necessity reviews, application of clinical guidelines in decision making and for health promotion and education programs
  
• Assist is establishing corporate and regional programs to enhance quality of care reduce medical costs and achieve positive health outcomes.
  
• Serves as a clinical resource and subject matter expert to both clinical and non – clinical staff.
  
• Perform clinical reviews and conduct peer to peers.
  
• Conduct discussions with physicians in the network regarding HEDIS metrics, medical policies, utilization management, claims editing, use of resources and quality.
  
• Perform clinical data review of HEDIS compliance and develop strategic initiatives to increase patient compliance.
  
• Perform high dollar claims and complex case reviews.
  
• Participate in inter-rater reliability activities.
  
• Participate in committees and workgroups to achieve department and corporate objectives.
  
• Participate in health plan Joint Operating Committees.
  
  
  Qualifications:
  
  • 
    
  • Doctorate from an accredited school of medicine (M.D.) or osteopathy (D.O.) required.
    
  • Seven (7) years of clinical experience or any combination of education and experience, which would provide an equivalent background.
    
  • Two (2) years of previous medical director experience working for a health plan, medical group, or hospital in a utilization management, quality management or medical management preferred.
    
  • Current unrestricted state of Nevada, Arizona, Oregon, Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) license or ability to obtain license.
    
  • Board certified or board eligible and working towards certification in a specialty approved by the
    
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    • American Board of Medical Specialists or the American Board of Osteopathy
      
      
      
    • Certification in Utilization Review and Health Care Quality & Management is preferred.
      
    • Knowledge of HEDIS, NCQA, and CMS Stars Programs
      
    • Ability to effectively communication with external physicians and organizations
      
    • Proven leadership, problem solving and the ability to manage multiple priorities.
      
    • Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
      
    • Results oriented and the ability to take ownership for initiatives and collaborate with cross-functional teams to achieve department and corporate goals.
      
    • Demonstrate skill with Microsoft Office Suite and web-based program.
      
    • Understanding of health plan and medical group functions related to utilization, care, as well as HEDIS/STAR s and NCQA. Familiarity with CMS regulations and standards.
      
    • Basic knowledge of evidence-based clinical decision support guidelines (Inter Qual/Milliman).
      
    • Basic knowledge of CPT coding and guidelines and how they relate to quality data capture.
      
    • Other related skills and/or abilities may be required to perform this job.
      
      To apply and learn more about this position please email a copy of your cv to
      
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Keywords: Hybridge Staffing, Las Vegas , National Medical Director Utilization Management - Quality Management, Executive , Las Vegas, Nevada