Lead Medical Director; Hybrid

Resp & Qualifications Purpose

Under leadership of the Chief Medical Officer, promotes and supports the corporate mission of transforming the health care experience with and for our members and communities through developing, defining and recommending uniform policies related to medical, behavioral health, technology assessment, quality, and credentialing. Represents the company interfacing with healthcare delivery partners and other key external constituents and stakeholders. Provides expert advice, advocacy and counsel to executive and administrative leadership.

We are looking for an experienced clinical leader in the greater Baltimore metropolitan area who is willing and able to work in a hybrid model. The incumbent will be expected to work a portion of their week from home and a portion of their week at a Care First location based on business needs and work activities/deliverables that week.

• Provides advice and counsel to executive and corporate administrators on medical and administrative matters related to medical practice and care delivery. Provides consultation to internal public policy leaders regarding legislative agenda and mandates. Represents Care First/ Health Services with external constituents and stakeholders such as health care delivery partners, Insurance Commissioners, media, and regional medical societies.
• Ensures that the provision of health care service to the membership is compliant with the medical policies and standards. Participates in medical necessity reviews, including pre-service reviews, concurrent reviews of inpatient and post-acute care, and appeals. Serves as key resource for network physicians for peer-to-peer case discussion.
• Directs and collaborates with the activities of key corporate committees including Quality Improvement Advisory Committee, Credentialing Advisory Committee, Care Management Committee, Technology Assessment Committee, Delegation Oversight Committee, Pharmacy & Therapeutics Committee, and other committees and task forces as appropriate.
• Contributes to the thought leadership and supports all areas of Health Care Services including Quality, Provider Collaboration and Networks Transformation, Value Based Care and Regional Care Management, Community Health & Social Impact, Health Informatics, Clinical Programs Oversight and more.
• Assists with directing, coaching, and guiding associates to implement departmental, divisional, and organizational mission/goals. Evaluates performance of team members and sets goals within the context of the corporate policies and procedures.

This position manages people.

Medical degree from an accredited medical school, and completion of an American residency program.

• MD – Physician – State Licensure Current medical license in Maryland without restriction.

• 5 years Clinical experience and 5 years administrative experience in a managed care setting.
• Current medical license and board certification in Maryland, or DC, or Virginia without restriction; and board certification. Previous experience as medical director for a health care company.

• Previous experience as medical director for a health care company and/or payer organization.
• Working knowledge of both commercial and government programs lines of business.

• Proficient in utilization management processes, quality assurance standards, and managed care.
• Strong people management and leadership experience in a clinical environment.
• Writes and presents effectively; adjusts to fit the audience and the message; strongly gets a message across.
• General understanding of health care claims data, trend analysis, and insurance operations and products.
• Skilled in coordinating and collaborating with physicians and other internal and external stakeholders including regulatory agencies, media, state and local health department leaders, and more.
• Demonstrated application and knowledge of current and emerging practice guidelines.
• Experience using data to make data driven business decisions.
• Must be able to meet…