• Primary responsible physician for fulfilling health plan contract case review requirements, which includes review of cases sent for Second Level Review
• Primary medical director leading utilization management and case management efforts. This includes conducting Reviews with Case Managers and Utilization and Peer to Peer reviews, establishing these guidelines, and implementing/using nationally recognized guidelines (i.e. IQ, Milliman). Identify trends, as well as anomalies, by working with inter disciplinary analytics team to research errors, unauthorized or non-covered services to improve accuracy in delivery of covered services, reduce over utilization, costs and improve outcomes
• Responsible for operational oversight and excellence of utilization management, alongside nurse/PT, clinical executives
• Key to role is also the ability to help develop and work metrics/dashboards to track performance (clinical and financial outcomes) and leverage in discussion with health plan
• He/she will develop a deep clinical understanding of the company's model and play an important role interacting with plan medical director(s)/CMO’s and primary care providers from key MSO’s – ability to make strong clinical and quality arguments to health plans and PCP’s is key
• Work alongside senior management, network medical director, and provider relations to build and maintain the relationships with health plan and MSO clinical leadership
o Local health plan medical directors, medical associations, hospitals, health systems, and regulatory bodies
• Support in audits, compliance requirements, etc with regulatory bodies and customers
• Opportunities to also design innovative new clinical and quality programs, Home Care (i.e. Hospital at Home) programs, work with industry leaders through OHS Advisory Board, and grow professionally and within the company into more senior role(s)
Fantastic opportunity to build the QI initiatives for an expanding full service home health company in South Florida. Their unique PAC management model enables patients to remain in their home and our plan partners receive the benefits of an outcome driven, value-based relationships. Currently serves over 600,000 Medicare Advantage lives in multiple markets.
The Senior Medical Director is responsible for the leadership of medical management activities. This encompasses primary responsibility for both operational and clinical excellence across utilization and case management in a unique, at-risk, home-based services model. As such, the role includes the
- design and implementation of medical and quality programs/policies, constant evaluation of opportunities for improvement, coordination/collaboration with other providers
- strong understanding of how to leverage data and clinical know-how in a fast-paced care delivery setting.
- He/she is part of the leadership team setting the strategic direction and goals for medical management. He/she is also partially
responsible for maintaining and cultivating relationships with local providers and health plan medical directors.
- Finally, he/she will support the executive team and clinical staff in strategic planning, compliance, UM, care management and process improvement to deliver efficient high quality, affordable care to all in the home and post-acute settings. Experience with medical management of Medicare and / or Medicaid Products is required.
• Minimum 5 years in clinical practice of adult and / or Geriatric patients
o Relevant specialty training a plus
o Experience with home-based services, SNF, or broader post-acute a plus
o Experience with plan quality/HEDIS/related a plus
• Minimum 3 years Health Plan UM, QI and Provider Relations Experience or equivalent Medical Management in a similar setting
• Previous experience in Peer to Peer, Utilization Review, Evidence Based Practice, Population Health and Chronic Care Program Management preferred
• Diplomatic and Collaborative Interpersonal, Communication, Listening and Presentation skills.
• MD or DO
• Board Certification or Equivalent in Internal Medicine, Geriatrics, Emergency Medicine or Rehab Medicine Preferred
• Active FL License