Medical Director - Well Sense Health Plan
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POST DATE 8/11/2016
END DATE 10/16/2016
BMC HealthNet Plan
JOB DESCRIPTIONThe Medical Director will support Well Sense Health Plan in New Hampshire (NH) in all aspects of the clinical program development and execution. S/he will serve as the primary clinical contact for Well Sense, providing day-to-day coordination of the Well Sense staff of the Office of Clinical Affairs (OCA) in all areas of medical management including utilization review, care and population management, concurrent review, credentialing, quality, appeals and grievances, pharmacy management and network management. Represents the Office of Clinical Affairs in developing and maintaining relationships with governmental organizations, regulatory groups, healthcare providers, and other external stakeholders. Maintains dual reporting relationships with the Well Sense Executive Director (ED) and Chief Medical Officer (CMO).
* In collaboration with departmental managers and directors, is responsible for NH OCA staff operations. Represents the CMO in New Hampshire and other locations as requested.
* Provides clinical leadership for Well Sense in the statewide development and growth of state funded and ACA-related managed care programs. In collaboration with the Executive Director, builds and maintains strong relationships with stakeholders including the NH Department of Health and Human Services, providers and member advocacy groups, serving in an advisory capacity on matters pertaining to program expansion.
* Provides clinical case review, consultation and oversight for all utilization management activities.
* Conducts review of prior authorizations, concurrent reviews and retrospective reviews that do not meet standard criteria and determines coverage.
* Conducts clinical review of appeals and grievances.
* Develops and supports clinical initiatives to support department quality improvement and utilization management goals
* Collaborates with hospital physicians, medical directors, primary care physicians and nurse case managers in daily activities and initiatives to improve the health of the population, the quality and experience of care our members receive, and lower the overall cost of care at the population level.
* Leads the NH Provider Advisory Committee
* Participates in and chairs clinical committees as assigned by CMO
* Participates in Well Sense and external committees as assigned by the Executive Director or CMO
* Supports quality, credentialing and pharmacy committees and activities
* Provides input to the strategic planning process for the Office of Clinical Affairs as requested.
* Supervision of NH OCA staff through a matrix reporting structure with OCA department directors and managers.
* Indirect technical direction is provided to the organization.
* General direction is received weekly from ED and CMO.
* Graduate as a Medical Doctor from an accredited college of medicine is required.
* 8-10+ years of related experience is required including a minimum of 5 years direct clinical experience and a minimum of 3 years experience in medical management in a managed care setting.
Competencies, Skills, and Attributes:
* Excellent demonstrated clinical skills and knowledge
* Excellent written and verbal communication skills.
* Comprehensive knowledge of accrediting organizations such as NCQA.
* Comprehensive knowledge of InterQual protocols, HEDIS, and other quality measures.
* Knowledge of federal and state Medicaid regulations, guidelines, and standards.
* Knowledge of managed care principles and processes.
* Ability to work independently with intermittent supervision.
* Adhere to appropriate turn-around-times and deadlines while maintain results of high quality and reliability.
* Proven leadership skills and relationship building
* Ability to manage staff in a matrix organization, balancing local needs of Well Sense office with the departmental and other needs within OCA.
* Ability to manage during times of uncertainty and complexity.
Certification or Conditions of Employment:
* Pre-employment background check
* Board certification in recognized medical specialty
* Current unrestricted licensure as an MD in New Hampshire.
Working Conditions and Physical Effort:
* Work is normally performed in a typical interior/office work environment.
* No or very limited physical effort required. No or very limited exposure to physical risk.
* Ability to travel to locations within New Hampshire and Massachusetts
* Regular and reliable attendance is an essential function of the position.