Family Practice - OB Physician

Position: Family Practice - Without OB Physician
Primary Purpose

Reviews requests for prior authorization and appeals for approval or denial of claims payment based on medical necessity. Oversees medical coordination required for effective utilization and quality management of the health plan network. Supports the clinical activities of PCHP Utilization Management, Quality Management, Clinical Policy, Technology Assessment, Credentialing, Population Health and Fraud, Waste and Abuse Functions to assure comprehensive, high quality health care to plan members in accordance with managed care and PCHP policies.

Monitors clinical care needed to produce optimal health outcomes and cost-effective care.

Minimum Specifications

Education
Must have successfully completed an Accreditation Council for Graduate Medical Education (ACGME) or American Medical Association (AMA) approved residency in an appropriate specialty to the PCHP population.

Experience

• At least five years of clinical practice experience in a specialty relevant to the care of PCHP members. OB/GYN experience preferred.
• At least three years of experience in the care of populations relevant to the PCHP population or managed care.
• Experience in the development of medical policies, procedures and programs is preferred.
• Qualifications to perform clinical oversight for the services provided by the health plan to include but not limited to education, training or professional experience in medical or clinical practice preferred.
• Past participation in a managed care UM committee preferred.

Equivalent Education and/or Experience

Certification/Registration/Licensure

• Must be currently licensed for the practice of medicine in the State of Texas.
• Must meet and maintain licensing and registration requirements as required by the State of Texas for Managed Care Medical Directors.

Required Tests for Placement

Skills or Special Abilities

• Must be philosophically oriented to the managed care concept of health delivery.
• Must have a working knowledge of managed care principles.
• Must demonstrate strong leadership, organizational, interpersonal, and verbal skills including demonstrated ability to work efficiently and communicate with executive management, physicians groups, community and provider organizations, and persons of diverse socioeconomic backgrounds.
• Must be able to demonstrate a working knowledge of Texas Medicaid Regulations and their interpretation.
• Must demonstrate effective supervisory, administrative and management skills including computer literacy.
• Must be able to demonstrate patient centered/patient valued behaviors.
• Must understand and demonstrate knowledge of principles of care coordination and collaboration, population health and social determinants of health, clinical evaluation of evidence based care and value based purchasing.
• Must be familiar with the role of pharmacy and behavioral health in managing health care.
• Ability to create, review and interpret treatment plans.
• Ability to adapt to changing priorities.
• Demonstrated ability to deal with confidential information.
• Demonstrated negotiation skills.
• Ability to remain calm under pressure.
• Ability to apply medical knowledge and principles to business challenges in order to achieve significant member, business, and quality outcomes.
• Ability to be detail-oriented and have a "hands-on" approach.

Responsibilities

Reviews prior authorization and appeals request for approval or denial of claims payment based on medical necessity.

Performs peer to peer calls as necessary to support the utilization management process.

Provides clinical oversight for utilization management, disease management and quality management activities as assigned by the PCHP Chief Medical Officer or Sr. Medical Director including participation in development of medical policies and procedures for coverage and authorization and clinical standards and guidelines based on evidence-based medicine.

Analyzes data to establish health care provider profiles and define acceptability of physician performance, conducts review of provider applications and qualifications, and participates in the review process of providers who fail to meet required standards, site and medical record reviews, as appropriate, to ensure adherence to managed care and PCHP policies.

Assists the Sr. Medical Director and the Pharmacy Director of PCHP in overseeing and administering the pharmacy benefit for PCHP members including coordination of care between the Medical and Pharmacy benefits.

Assists the Sr. Medical Director in oversight, evaluation, and administration of the clinical aspects of PCHP fraud, waste and abuse programs.

Participates in development, implementation, and monitoring of annual goals and objectives for PCHP that support the mission and objectives of Parkland.

Assists in identifying member and provider needs for education and health promotion. Participates in assessment of existing education programs offered to providers, developing and evaluating such programs, as required, to ensure that managed care service area and PCHP needs are…