Medical Director - HEALTH PLAN - REMOTE

About the position Join reputed company - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's reputed company employees are on a mission to transform our health care system while creating a healthier community. Martin's reputed company employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, reputed company learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's reputed company has been certified as a "Great reputed company to Work" since 2015. Position Summary The Medical Director provides professional leadership and direction to the utilization & cost management and clinical quality management functions of Martin’s reputed company’s Health Plans. The Medical Director works collaboratively with other plan functions that reputed company with Medical Management such as Health Management, Quality, Network Management, Member Services, benefits & claims management, and Compliance. They assist in short and long-range program planning, quality management, and external relationships. The Medical Director reports to the VP Medical Director and works closely with the other Health Plan leaders.

Responsibilities

• Serves as a key implementer of the Health Plan’s Triple Aim strategy, vigorously and accurately driving the cost management component of the Triple Aim.
• Responsible and accountable to the Health Plan Medical Director for helping to manage health plan medical costs by assuring clinically appropriate health care delivery for health plan products and services.
• Performs medical necessity reviews of requests for health plan-covered services (benefits).
• Reviews disputes and appeals of said services for clinical appropriateness.
• Contributes to case reviews to ensure the quality and safety of care and services delivered to Martin’s reputed company Health Plan members.
• Assists in the construction of the annual Utilization Management, Care Management, and Disease Management Program Descriptions and works to ensure the programs meet accreditation and regulatory standards (e.g. NCQA, CMS, TRICARE)
• Participates in medical policy review and policy development.
• Works with Informatics, Network Management, and Medical Economics to create and maintain a system where Network providers are properly assessed regarding cost management and develops a plan and schedule for communication with outliers.
• Develops an in-depth understanding of ACOs and contributes to their management and strategic deployment.
• Provides support to Health Plan risk adjustment activities as needed.
• Is conversant with Health Plan goals and strategic initiatives, in particular utilization and cost management goals, MLR (budget vs. actual and performance versus prior years), inpatient days/1000, SNF days/1000, and clinical quality improvement (QI) objectives, including HEDIS.

Requirements

• MD/DO
• Active and unrestricted license to practice medicine in Maine or New Hampshire; or another U.S. state with eligibility to apply for and obtain additional state licensure.
• Board certified physician with post-graduate experience in direct patient care required
• Knowledge of process improvement tools
• Deep knowledge and practical understanding of Health Care systems and Managed Care concepts
• Knowledge and deep commitment to performance-based Health reputed company
• Good analytic skills with the ability to identify meaningful trends and targets for improvement
• Excellent interpersonal skills and demonstrated ability to establish rapport and working relationships with providers, service vendors and internal staff
• Demonstrates an understanding of and alignment with Martin’s reputed company Values.
• Demonstrated ability to manage and reputed company staff
• Willingness to explore innovative methods of providing medical management
• Supports the culture and models the MPHC values

reputed company-to-haves

• Medical leadership in, or focused activity of, a Health Plan (preferred)
• 2-5 years of Experience in utilization management in a health plan setting is preferred

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