This is an exceptional opportunity with our top tier managed care client to support the Medicaid Clinical Operations business in the state of West Virginia.
The ideal candidate will be responsible for the administration of medical services for company health plans including the overall medical policies of the business unit to ensure the appropriate and most cost-effective medical care is received.
Interprets existing policies and develops new policies based on changes in the healthcare or medical arena.
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.
Serves as a resource and consultant to other areas of the company, may chair or serve on company committees, may be required to represent the company to external entities and/or serve on external committees, conduct peer clinical and/or appeal case reviews and peer to peer clinical reviews with attending physicians or other ordering providers to discuss review determinations, provides guidance for clinical operational aspects of the program.
Supports the medical management staff ensuring timely and consistent responses to members and providers.
Requires M.D. or D.O.;
Board certification approved by the American Board of Medical Specialties required where applicable to duties being performed (Internal Medicine or Family Medicine or double-boarded Internal Medicine/Pediatrics strongly preferred).
Must possess an active unrestricted medical license to practice medicine or a health profession in the state of WV or Must be able to obtain a WV license (expenses will be reimbursed).
West Virginia resident highly preferred.
5 years of clinical experience or any combination of education and experience, which would provide an equivalent background.
Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Managed care experience highly preferred.
Proficiency with MS products (Word, Excel) and familiarity with large electronic system (for example EMRs) required.