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Medical Director (20 hours per week)

    • Job Tracking ID: 512689-621743
    • Job Location: Milwaukee, WI
    • Job Level: Management
    • Level of Education: Doctoral Degree
    • Job Type: Part-Time/Regular
    • Date Updated: May 21, 2018
    • Years of Experience: 7 - 10 Years
    • Starting Date: ASAP
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Job Description:

This part-time professional position is responsible for oversight of the utilization management, credentialing, and quality management functions. Provides medical expertise and acts as senior medical resource for review of complex medical and social cases. Acts as primary liaison with physicians. This position reports to the Chief Medical Officer.

  1. Assist in the development of ongoing quality improvement of iCare services, i.e., credential reviews, quality improvement programs, disease management and member satisfaction programs.
  2. Assist iCare to achieve its principal programmatic goals — coordinating medical, behavioral health and social services, improving access, and maximizing resources.
  3. Assist in development of outcome measures to evaluate the effectiveness of the iCare care coordination model and conduct ongoing monitoring of the model’s effectiveness, to include recommendations for changes and improvements consistent with organizational goals and budgetary constraints.
  4. Assist in designing and implementing programs that promote health and reduce the risk and/or onset of illness.
  5. Assist in selecting and disseminating treatment guidelines as required by State Contract or CMS Contract.
  6. Work in conjunction with legal counsel and senior management on potentially litigious utilization or case management issues.
  7. Assist in the design of policies and programs for iCare to achieve measurable levels of effectiveness, efficiency, and customer and provider satisfaction.
  8. Exercise professional medical judgment in accordance with acceptable community standards.
  9. Participate in the review and approval of authorization activities for medical review purposes. Assume responsibility for approving or denying cases for medical necessity and/or clinical appropriateness.
  10. Guide selection and interpretation of utilization review criteria.
  11. Ensure the clinical decision management and provider profiling support tools are effective, current and credible.
  12. Work in conjunction with senior management and various committees to determine strategy and management direction for utilization management, quality management and credentialing initiatives.
  13. Develop a panel of independent (non-participating and participating) physician advisors to cover the need for specialty-matched peer reviews as needed.
  14. Represent iCare in external professional settings, meetings, conferences, etc.
  15. Contribute to the development of policies, procedures and programming to support compliance with the State contract and CMS contract and efficiencies within the organization.
  16. Participate in the pre-grievance review process and represent iCare at fair hearings.
  17. Arrange for appropriate coverage in the event of absence.
  18. Has profit and loss responsibilities.
  19. Assist in claims reviews and appeals
  20. Assist Network Development/Provider Relations in an advisory capacity.
  21. Assist in efforts to maximize financial reimbursement to the company through projects such as HCC scores, vent reviews, identifying cases for subrogation.

Experience and Skills:

1. Current non-restricted license to practice medicine in the State of Wisconsin.

2. Board certification in specialty approved by the American Board of Medical Specialists.

3. Knowledge of and experience with managed health care.

4. Well-developed supervisory, problem solving and interpersonal communication skills.

5. Knowledge of and familiarity with Medicare and Medicaid programs.

6. Knowledge of and experience with Quality Assurance Programs.

7. Knowledge of software programs, Excel, Access, Word Outlook.


 

 
 
 
  • Independent Care Health Plan
  • 1555 RiverCenter Drive, Suite 206
  • Milwaukee, WI 53212
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  • Copyright © 2017 Independent Care Health Plan