Medical Director

    • Job Tracking ID: 512935-735506
    • Job Location: Jefferson City, MO
    • Job Level: Management
    • Level of Education: Masters Degree
    • Job Type: Part-Time
    • Date Updated: June 25, 2020
    • Years of Experience: 10 - 15 Years
    • Starting Date: ASAP
    • Salary Type:: Hourly
    • Rate:: $100-$115 per hour. 4-10 hours per week with possible opportunity to increase
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Job Description:

Job Summary

The Medical Director is responsible for the administration of medical services for company health plans including the overall medical policies of the business unit to ensure the appropriate and most cost-effective medical care is received and assists the Senior Medical Director as needed in the day-to-day clinical oversight of the UM Program.

The Medical Director conducts member case reviews requiring physician involvement such as prior authorizations and appeals. Provides peer-to-peer consultations with providers and clinical expertise to staff on utilization and case management reviews. Provides mentoring for employed or contract physicians and participates on clinical project teams.

Key Result Areas

Primary duties may include, but are not limited to:

  • Conducts high-quality member case reviews and/or appeal case reviews.
  • Provides peer to peer clinical reviews with attending physicians or other ordering providers to discuss review determinations.
  • Promotes provider understanding of utilization management and quality improvement policies, procedures and standards.
  • Supports the medical management staff ensuring timely and consistent responses to members and providers
  • Provides clinical expertise, oversight and leadership for staff to ensure members receive safe, effective and cost-efficient services.
  • Provides clinical input on case management reviews/services working closely with the Case Management clinical staff.
  • Interprets existing policies and assists in developing new policies based on changes in the healthcare or medical arena.
  • Identifies and assists in developing new opportunities for innovation in utilization management, case management, health management or other areas to increase effectiveness, quality and outcomes.
  • Stays abreast of industry, medical and technology trends.
  • Serves as a resource and consultant to other areas of the company and may chair or serve on company committees/projects.
  • Participates on various teams to provide clinical input on medical policy reviews and development and may participate on committees that develop programs impacting clinical interventions, utilization management and case management and health management.
  • Represents company and provides formal presentations to clients/external entities at client meetings and/or conferences,
  • Assists with oversight of operational and administrative processes to ensure Medical Management standard operating policies remain in compliance with industry standards, licensing, and accreditation/certification boards.
  • Ensures accuracy and confidentiality is maintained with all documentation.
  • Performs other duties as assigned or needed.

Experience and Skills:

Minimum Qualifications

  • Requires M.D. or D.O
  • Must possess an active unrestricted medical license to practice medicine or a health profession.
  • Board Certification approved by the American Board of Medical Specialties required where applicable to duties being performed.
  • Internal Medicine, Emergency Medicine, General Surgery certified preferred.
  • 10 years of clinical experience or any combination of education and experience which would provide an equivalent background.
  • Utilization Review background a plus.
  • Managed care experience, either with a medical group or health plan preferred.
  • Knowledge/understanding of determining medical necessity, utilization review principles, and Continuous Quality Improvement theory and practice.
  • Experience with performance measurements (HEDIS, NQF and other systems), accreditation standards (NCQA, URAC), member satisfaction and patient safety preferred.
  • Proficiency with the use of a variety of software applications (e.g., Microsoft Word, Excel, and PowerPoint).
  • Ability to travel out of the office to meet with clients/external entities.
  • Advanced presentations skills with the ability to plan, facilitate and present at meetings, conferences, etc.
  • Requires strong oral, written and interpersonal communication skills, problem solving skills, facilitation skills.
  • Ability to provide excellent customer service/professionalism, work efficiently, perform multi-tasking, prioritize tasks, and meet tight deadlines.
  • Ability to mentor and develop staff and communicate with other physicians and team members effectively and respectfully.
  • Ability to research, interpret and apply medical scientific evidence to case reviews and interpret aggregated utilization data to identify areas of outlier and/or aberrant practices.
  • Possess a high degree of integrity and discretion, as well as the ability to adhere to both company policies and best practices.
  • Ensure compliance with security practices and procedures, including HIPAA and HITRUST standards.
  • Ability to efficiently and effectively perform the Key Result Areas with or without a reasonable accommodation without posing a direct safety threat to others or self.
  • Protect and enhance the Core Purpose and the Core Values of AmeriBen.

AmeriBen is an Equal Opportunity/Affirmative Action Employer committed to creating an environment of diversity and inclusion for equal employment and advancement opportunities to all employees and applicants for employment. All qualified applicants will receive consideration for employment without regard to race, religion, color, age, national origin, sex, sexual orientation, gender identity and/or expression, genetic information, disability, veteran or military status, or any other category protected by federal, state and/or local law.

If you are unable to use our online application process due to a disability, please contact the Human Resources Department at humanresources@ameriben.com