An exciting opportunity to impact patient outcomes. This is a hybrid role (remote/some office) As a clinician within a health plan, you will be responsible for the administration of medical services for including the overall medical policies or clinical guidelines of the plan to ensure the appropriate and most cost-effective medical care is received.
The objective is to drive direction of the plan related to cost of care and other plan directives. The ideal candidate will work with the market plan president during meetings with State Regulator.
Supports the Medical Management staff to ensure timely and consistent responses to members and providers.
Provides guidance for clinical operational aspects of a program.
Conducts peer-to-peer clinical reviews with attending physicians or other providers to discuss review determinations, and patients’ office visits with providers and external physicians.
May conduct peer-to-peer clinical appeal case reviews with attending physicians or other ordering providers to discuss review determinations.
Interprets existing policies or clinical guidelines 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 efficient and effective care.
Identifies and develops opportunities for innovation to increase effectiveness and quality.
Provides expertise, captures and shares best practices across regions to other medical directors.
May chair or serve on company committees, may be required to represent the company to external entities and/or serve on external committees.
Requires MD or DO and Board certification approved by one of the following certifying boards is required, where applicable to duties being performed, American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA).
Internal Medicine, Pediatrics, OBGYN, Surgery or Emergency Medicine background required
Requires active unrestricted medical license in NJ
Minimum of 10 years of clinical experience; or any combination of education and experience
Utilization Review management/peer review experience is required
Competitive base salary with short term incentives, 401k, stocks and other benefits available.