HealthCareMatch Careers

Our client is currently hiring for a Medical Director in Wheeling, WV. If interested please send over an updated resume right away by applying to this role!

Job Title: Behavioral Health Medical Director
Department: Clinical Services
Reports To: Chief Medical Officer
Location: Wheeling, WV (OPEN TO RELOCATION)
Hours: Monday to Friday, 8:00 am to 5:00 pm

Required Qualifications:

Active physician license without restriction.
Meets all THP credentialing requirements.
Three years managed care experience in HMO setting preferred.
Board certification.
Minimum of five years post graduate clinical experience.

Desired Qualifications:

Basic computer literacy.
Prior leadership roles while in clinical practice is desirable.
Demonstrated ability to work in unison with other professionals and non-professionals in a respectful and harmonious manner

Position Summary:

Medical Professional(s) responsible for direction and oversight of healthcare services provided to Plan members to ensure the delivery of cost-effective, quality services.
The Medical Director shall be responsible for Medical Direction of all activities of the Quality Management and Utilization Management Programs of our client.
This will be a Dyad relationship with the Directors of Utilization and Quality Management and Pharmacy Management.

Essential Functions and Responsibilities:

Provide Physician oversight for activities related to the company?s Utilization Management, Disease Management and Quality Management programs ensuring compliance with NCQA, Medicare, Medicaid, and other regulatory entities.
Play an active role in preparing for related audits and information requests from such entities.
Establish the highest standards of best medical practices for care provided to members through participation in the development of clinical practice guidelines and selection and procurement of suitable proprietary criteria and clinical pathways.
Provide physician education regarding utilization management and quality management protocols and initiatives.
Work with individual physicians or physician groups to achieve acceptance and understanding of medical appropriateness criteria, practice guidelines and patient care programs.
Carry out specific functions as outlined in the Utilization Management Program including: - Play a leadership role in the development and implementation of the Utilization Management Program including assisting in the development of the annual work plan and program evaluation. Serve as chairperson and or member of various utilization management committees as set forth in the Utilization Management Program Description. - Review clinical utilization and the delivery of acute care to members on a daily basis. Maintain daily interaction with hospital review, case managers, care managers, disease managers, pharmacy managers, claims managers and other staff. - Review all cases where medical appropriateness is questioned and provide overall responsibility for authorization or non-authorization based on medical appropriateness of the health care services requested. - Available to communicate telephonically with practitioners in case review matters. - Available as needed to provide twenty-four hour coverage for case review matters. - Actively participates in the functioning of the plan appeal and grievance procedures.
Works directly with Network Development staff to develop and coordinate effective provider education/intervention programs including providing input into provider training and education programs, review of provider manuals and direct contact with providers as needed.
Perform other duties and special projects as assigned to accomplish the goals of the organization.

Again if interested please apply immediately so I can review your resume and we can get an interview scheduled!

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