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Job Summary
Reporting to the Senior Medical Director of UM, the Per Diem UM Medical Director will be responsible for:
Performing daily medical reviews, appeals, participating in appeal panel as appropriate, correspondence regarding review determinations and physician peer review activities.
Identifying and implementing evidence-based practice guidelines throughout the provider network. · overseeing the quality of clinical care for network and non-network providers.
Utilizing evidence-based standards in making coverage determinations.
Management policies; meeting health plan inter-rater reliability guidelines.
Work Arraignment: Remote and not to exceed 15 hours per week, including rotating weekend and evening coverage as assigned.
Accountabilities:
- Ensures the provision of quality and clinically sound services to all Enrollees by associates and Providers.
- Serves as medical advisor and manager for all clinically related activities.
- Assures that organization medical policies and procedures adhere to contractual obligations.
- Performs clinical case reviews in conjunction with Medical Excellence Department.
- Demonstrates knowledge of prescribed and established medical procedures and practices.
- Maintains familiarity with federal, state and local regulations that may pertain to the medical and clinical operations.
- Maintains compliance with applicable regulatory guidelines, AmeriHealth Caritas clinical policies and procedures, and contractual obligations.
- Manages day-to-day operations and monitors the integration and processing of members to optimize appropriate use of behavioral and physical health services.
- Participates with Quality Improvement and Medical Excellence in the identification and analysis of medical and behavioral health information to develop interventions to improve clinical effectiveness of medical management strategies.
- Works closely with a multidisciplinary team to ensure behavioral health management and quality management programs are meeting contractual obligations.
- Works with the leadership of the Quality Improvement and Medical Excellence departments to develop competent clinical staff.
- Attends case management meetings and monthly rounds as scheduled.
- Collaborates with the integrated case management team, during scheduled meetings and informally as needed.
- Thoroughly documents all care coordination activity in the member medical record in the electronic case management documentation system.
- Adheres to AmeriHealth Family of Companies (ACFC) policies and procedures and supports and carries out the ACFC mission and values.
- Other duties as assigned.
Education/Experience:
- Doctor of Medicine (MD) or Doctor of Osteopathic Medicine licensed to practice as a medical director; additional state licensure required in all states where ACFC has a line of business, and that application is expected within 120 days of hire.
- Must be Board-certified in a specialty with a current and unrestricted license.
- Must be clear of any sanctions by the applicable state or Office of the Inspector General.
- Must not be prohibited from participating in any Federally or State funded healthcare programs.
- 1 to 3 years of Health Plan experience.
Other Skills:
- Strong written and oral communication skills-required.
- Demonstrated competency in use of healthcare data.
- Demonstrated excellent interpersonal communication skills and presentation skills.
- Experienced in conflict resolution and negotiation.
- Understanding of and expertise in quality improvement and medical economics.
- Strong leadership skills.
- Excellent analytical and problem-solving skills.
- Demonstrated ability to access department’s work quality and develop / implement process improvements to achieve regulatory and oversight compliance.
- Maintain current knowledge of and applies all applicable licensing, regulatory and industry standards.
At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.
Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.
Discover more about us at www.amerihealthcaritas.com.
Our Comprehensive Benefits Package
Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.