Associate Medical Director

All Care Health Headquarters, Grants Pass, OR, US

3 days ago Requisition

All Care Health offers competitive wages, an excellent benefits package including affordable healthcare, 401k retirement, wellness programs, and flexible schedule options.

This position is responsible for overseeing the day-to-day medical management activities of the department, including but not limited to utilization reviews, appeals and grievances, case consultations, and recommendations, by performing the following duties.

• Assists with the development and maintenance of all medical and departmental policies and procedures to support the utilization management process.
• Works with the Chief Medical Officer to establish, implement, and monitor a departmental plan to address resource and cost utilization to ensure optimal health plan member experience and corporate performance and fiscal goals are met.
• Collaborates with the Chief Medical Officer and Director of Quality/Government Relations to ensure departmental compliance with all required regulatory and accreditation agencies.
• Makes clinical service determinations based on medical appropriateness, utilizing applicable criteria and guidelines and can deny requests based on medical necessity and/or not meeting criteria, policy, or appropriateness.

• Leads and/or participates in corporate and community committees, task forces, and project initiatives as business needs require.
• Serves as a subject matter expert in Medical Management interpreting regulatory requirements and coordinating processes to support requirements.
• Works with senior management to identify and develop health plan departmental objectives and strategies to maximize operations that support corporate strategies and initiatives.
• Coordinates the development and annual review of medical policies, procedures, and standards for the department to ensure they meet CMS, Oregon Health Plan, and NCQA requirements.
• Collaborates with Chief Medical Officer and Chief Quality and Compliance Officer to ensure departmental compliance with all required regulatory and accreditation agencies.
• Serves as a professional role model while supporting the organization’s mission, vision, and values in all departmental activities.
• Works with all types of members, regardless of age, ethnicity, medical or mental impairment, disability, or dissatisfaction with the Health Plan.
• Participates in organizational committees, including Credentialing, Patient Care, Quality Improvement and Pharmacy Committee as needed.
• Participates in departmental staff meetings, utilization management conferences, and case review sessions.
• Supports Medical Management staff activities that ensure members are receiving quality and efficient member care coordination.
• Ensures an optimal member experience maximizing customer satisfaction.
• Serves as lead Medical Management liaison to All Care Independent Physicians and other providers by collaborating with other health plan constituents and communicating departmental processes.
• Supports Chief Medical Officer in IPA physician recruitment and credentialing efforts.
• Refers situations to the Quality Committee, Corporate Compliance, Fraud & Abuse, or Legal Services when appropriate.
• Ensures Medical Management departmental compliance with all confidentiality and HIPAA requirements.
• Maintains punctual, regular, and predictable attendance.
• Works collaboratively in a team environment with a spirit of cooperation.
• Respectfully takes direction from leadership.
• Meets all required training including those listed in Relias Learning Module System (LMS).
• Performs other duties…