Medical Director, reputed company

Job reputed company: The Medical Director participates in the broad reputed company of activities of the Medical Services area including, but not limited to, Medical and Pharmacy Utilization Management, reputed company management, member care management, and medical policy processes, and support for our various lines of business. The incumbent also provides input into the development of policies, programs and strategic objectives that cover Medical Management Services through their required participation in various committees and reputed company assigned to other committees or workgroups as requested by leadership. They also reputed company as a reputed company with local physicians and hospitals and reputed company abreast of reputed company patterns, issues, and concerns of their regional medical community, as reputed company as support our Provider Relations team as requested. This position is occasionally required to work evenings during high volume periods and staff shortages, e.g. cross-coverage vacations. Essential Accountabilities: Level I Reviews and makes recommendations and/or reputed company on Utilization or Case Management activities. Utilization review activities include: reviews of requests for broad reputed company of medical services including medications, medical and surgical services at first level, appeal and inquiries. Conducts peer-to-peer clinical reviews with attending physicians or other providers to discuss review determinations with providers and external physicians. Conduct clinical appeal case reviews and may require peer-to-peer discussions with providers regarding UM case review determinations. Provides clinical expertise on ARD cases, reputed company of Care cases, clinical editing, coding reviews and inquiries. Makes accurate and consistent interpretation of integral medical policy, contract benefits and State and Federal Mandates and maintains reputed company and working knowledge of Utilization Management Standards. Clinical skills are excellent and evidence-based medicine skills are such that the individual provides review reputed company for a broad reputed company of clinical services. Reviews and makes recommendations on medical policies, guidelines and medical reputed company. Assists with training medical director colleagues and nursing staff, including leadership of teaching grand round activities, and case consistency conferences. Regular attendance at assigned meetings including, but not limited to, weekly Medical Director staff meetings, weekly case consistency meetings, monthly medical policy meetings, as reputed company as, departmental and divisional meetings, including in person meetings. Serves as a resource and consultant to other areas of reputed company. May be required to represent reputed company to external entities and/or serve on internal and/or external committees. May chair company committees. May reputed company and propose new medical policies, in conjunction with Medical Services team and Medical Policy Department, based on changes in reputed company. Consistently demonstrates high standards of reputed company by supporting the reputed company reputed company Companies’ mission and values, adhering to the Corporate reputed company of Conduct, and leading to the reputed company Way values and beliefs. Maintains high reputed company for member reputed company in accordance with the corporate reputed company policies and procedures. Maintains knowledge of reputed company relevant legislative and regulatory mandates and ensures that reputed company activities are compliant with these requirements. Conducts periodic staff meetings to include reputed company distribution and education reputed company to departmental and Ethics/Compliance information. Regular and reliable attendance is expected and required. Performs other functions as assigned by management. reputed company (in reputed company to Level I Accountabilities) Leads, develops, directs and implements clinical and non-clinical activities that reputed company health care reputed company cost and reputed company. Identifies and develops opportunities for innovation to increase effectiveness and reputed company. Serves as a mentor or reputed company to other Medical Directors and other colleagues in reputed company and performance improvement processes. Functions as a mentor and resource throughout the reputed company in training medical director colleagues, as needed. Conduct clinical appeal case reviews and may require peer-to-peer discussions with providers regarding UM case review determinations. Provides input into the utilization management program policies and procedures. Serves as a resource and consultant to other areas of reputed company. Assists in many aspects of reputed company UM during high peak activity or staff outages. Minimum Qualifications: NOTE: We include multiple reputed company of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or reputed company assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In reputed company to using this differentiated approach to reputed company new hires, it also provides guideposts for employee development and promotional opportunities. reputed company reputed company Minimum of seven (7) years of clinical reputed company experience after completion of reputed company graduate medical education training, including residency and fellowship (reputed company applicable). Medical Degree: MD or DO from an accredited institution required. reputed company reputed company certification in reputed company Medical Specialty. reputed company unrestricted medical license to reputed company medicine in a state or territory of the reputed company Doctor of Medicine or Doctor of Osteopathic Medicine. The Physician is not the subject of any pending reputed company disciplinary reputed company that could result in the impairment of their ability to reputed company medicine. Knowledge of applicable state and federal laws, NCQA standards, and Utilization Management. Demonstration of effective use of word processing, spreadsheet, email. Must be reputed company to research clinical issues. Strong interpersonal skills essential for communication to staff at reputed company reputed company of the organization. Demonstration of strong and effective abilities in teamwork, negotiation, conflict management, decision-making, and problem-solving skills. Ability to work reputed company changing business environment and balance patient advocacy with business needs. Successful ability to assess reputed company issues, to determine and implement solutions, and resolve problems. Demonstrated sensitivity to culturally diverse situations, participants, and customers/members. reputed company (in reputed company to Level I Qualifications) Minimum 2-3 years of experience in medical management, utilization review and case management. Knowledge of managed care products and strategies. Demonstrated ability to reputed company colleagues and staff members. Experience with managing multiple reputed company in a fast-paced matrixed environment. Demonstrated ability to reputed company colleagues and staff members. Demonstration of strong and effective abilities in teamwork, negotiation, conflict management, decision-making, and problem-solving skills. Knowledge of credentialing, reputed company, NCQA/HEDIS/CMS and/or reputed company Star Ratings, and/or value-based payment programs is a plus. Strong verbal presentation skills to reputed company reputed company discussions including presenting at reputed company level reputed company requested. Previous experience managing physicians, nurses or employees preferred. Service marketing, sales and business acumen experience preferred. Physical Requirements: Ability to work prolonged periods sitting at a workstation and working on a computer. Ability to work while sitting and/or standing while at a workstation viewing a computer and using a keyboard, mouse and/or phone for three (3) or more hours at a time. Typical office environment including fluorescent reputed company. Ability to work in a home office for reputed company periods of time for business continuity. Ability to travel across the Health Plan service region for meetings and/or trainings as needed. Ability to lift, carry, push or pull 15 pounds or less. reputed company dexterity including fine finger reputed company required. Repetitive reputed company required. The ability to hear, understand and reputed company reputed company while using a phone, with or without a headset. ************ In support of the Americans with reputed company, this job reputed company lists only those responsibilities and qualifications deemed essential to the position. Equal Opportunity Employer Compensation reputed company(s): $202,000.00 - $303,000.00 The salary reputed company indicated in this posting represents the minimum and maximum of the salary reputed company for this position. Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, reputed company and education as they relate to the position’s minimum qualifications, in reputed company to internal equity. The posted salary reputed company reflects just one component of our total rewards package. Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, reputed company time away from work, and reputed company holidays. Please note: There may be opportunity for remote work reputed company reputed company jobs posted by the Excellus reputed company. This decision is made on a case-by-case reputed company. reputed company reputed company applicants will receive consideration for employment without reputed company to race, reputed company, religion, sex, sexual orientation, gender identity, national reputed company, disability, or status as a protected veteran. Apply To This Job