Medical Director - Health Plan
North Seattle, WA (Northern Suburb near Lynwood)
*** Generous Relocation Package available to attract top talent from around the Nation! ***
Medical Director Job Summary:
Medical Director Profile:
- Serves as the primary liaison between administration and medical staff.
- Assures the ongoing development and implementation of policies and procedures that guide and support the provision of medical staff services.
- Maintains a working knowledge of applicable national, state and local laws and regulatory requirements affecting the medical and allied health staff.
- Expertise in Medicare as it relates to Utilization Management and Appeals standards, processes and policies, and Medicare STARS.
- Collaborates with the national Medicare team.
- Facilitates conformance to regulatory requirements.
- Reviews quality referred issues, focused reviews and recommends corrective actions.
- Monitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost-efficiency and continuity of care.
- Develops and implements medical policies.
- Conducts retrospective reviews of claims and appeals, and resolves grievances related to medical quality of care.
- Formal education including a Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree.
- Must hold and maintain an active unrestricted state license to practice medicine.
- At least 5 years directly applicable clinical practice experience, and board certification, in the US.
- Around 2 years of Medical Director experience working for a Managed Care Organization (Health Plan/IPA/HMO/TPA, etc).
- At least 3 years of Utilization Review /Quality Management program management
- Requires expertise in Medicare as it relates to Utilization Management and Appeals standards, processes and policies, and Medicare STARS.
- Demonstrated ability to communicate and educate providers regarding principles of Utilization Management and Quality Improvement.
- Prefer prior experience with peer review, medical policy/procedure development, provider contracting experience.
- Excellent written and verbal communication skills; and strong critical thinking, deductive reasoning and decision-making skills are needed.
- Ability to implement complex programs and to monitor implementation and modifications.