Medical Director opening in Las Vegas, Nevada.
National Medical Director Utilization Management Quality Management
Can work remote
Excellent compensation package and full benefits
- 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.
- 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 Click Here to Apply