This is an exceptional opportunity to do innovative work that means more to you and those we serve at one of America's leading health benefits companies and a Fortune 500  Company. 

 

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 and for the day-to-day management of medical management staff.

Primary duties may include, but are not limited to: 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.  

 

 

M.D. or D.O. 

Medicaid experience a plus

Must possess an active unrestricted medical license to practice medicine or a health profession. 

Previous experience in chart reviews, peer reviews and/or utilization reviews required

Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

We will also consider a 1099 contractor for this role.