Medical Director | Physician Executive | Managed Care
Job Title: Medical Director | Physician Executive | Managed Care
Employer: MMS Group
Location: Philadelphia, Pennsylvania
Job Type: Full-Time
Career Level: Experienced
Experience: 5-10 years
Education Level: Professional
Medical Director- Health Plan – Philadelphia OR Harrisburg PA
Amazing opportunity to join an MCO and improve quality of care and access to care for vulnerable populations. Physician will have an opportunity to lead and drive special projects and initiatives as a daily part of this role. Not all case review! Projects around quality, reducing red-admissions, controlling cost, wellness initiatives…and MORE!
PRIOR managed care experience is NOT REQUIRED.
The PA market has excellent leadership and collaboration!
Relocation is offered as well as generous benefits and bonus!
Preference for a physician with local ties and a passion for serving the vulnerable population.
- Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities.
- Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services.
- Supports effective implementation of performance improvement initiatives for capitated providers.
- Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members.
- Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.
- Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership.
- Oversees the activities of physician advisors.
- Utilizes the services of medical and pharmacy consultants for reviewing complex cases and medical necessity appeals.
- Participates in provider network development and new market expansion as appropriate.
- Assists in the development and implementation of physician education with respect to clinical issues and policies.
- Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components.
- Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care.
- Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality.
- Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment.
- Develops alliances with the provider community through the development and implementation of the medical management programs.
- As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues.
- Represents the business unit at appropriate state committees and other ad hoc committees
- MD or DO
- Board certified preferable in a primary care specialty (Internal Medicine, Family Practice, Pediatrics or Emergency Medicine).
- Must be an actively practicing physician.
- Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is preferred
- Experience treating or managing care for a culturally diverse population preferred.
- Board Certification through American Board Medical Specialties. – Current medical license (prefer PA)