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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

      • 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

        Keyphrases: health administration jobs, medical director jobs, hospital administration jobs, hospital administrative jobs, healthcare administration jobs, administration jobs, healthcare administrator jobs, medical administration jobs, chief medical officer jobs, medical director position jobs, associate medical director jobs, medical ceo jobs, healthcare ceo jobs, medical administrative jobs, executive director jobs

Keywords: Hybridge Staffing, Las Vegas , National Medical Director Utilization Management - Quality Management, Executive , Las Vegas, Nevada

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