Medical Director

Job : MCALLEN, Texas

Employment type:

Full-time Category:
Management Details: ACO MANAGEMENT SERVICES LLC;
Director;
Day;
Prominence Health; WFH Flexible; 40; USD $/Yr.; USD $/Yr.Posted:
Responsibilities Prominence Health is a value-based care organization bridging the gap between affiliated health systems and independent providers, building trust and collaboration between the two. Prominence Health creates value for populations and providers to strengthen integrated partnership, advance market opportunities, and improve outcomes for our patients and members. Founded in 1993, Prominence Health started as a health maintenance organization (HMO) and was acquired by a subsidiary of Universal Health Services, Inc.

(UHS) in 2014. Prominence Health serves members, physicians, and health systems across Medicare, Medicare Advantage, Accountable Care Organizations, and commercial payer partnerships. Prominence Health is committed to transforming healthcare delivery by improving health outcomes while controlling costs and enhancing the patient experience. Learn more at:

Job Summary:

Reporting to the Chief Medical Officer of Prominence Health Plan (PHP), the Medical Director will direct the development of goals and objectives and the activities related to their achievement for the Health Services Department of PHP which include Utilization Management, Care Management, Disease Management, Quality Improvement, Pharmacy Management, Risk Adjustment, and Community Provider Relations. The Medical Director will provide leadership for the above-mentioned departments and may be asked to participate with and lead other multi-disciplinary or cross functional task-oriented groups within PHP and as appropriate other internal and external units.

Staff Medical Directors hold an active, unrestricted, valid, and current licenses to practice medicine in Nevada, Texas, and/or Florida and are board-certified by a specialty board approved by the American Board of Medical Specialties or the Advisory Board of Osteopathic Specialists or a Doctor of Podiatric Medicine. They are qualified to render appeal determinations in addition to initial determinations and non-certifications.

Physician reviewers have access to consult with initial clinical reviewers, other medical advisors, licensed doctors, or peer reviewers through several modes of contact. This individual is qualified, as determined by the medical director or clinical director, to render a clinical opinion or determination about the medical or behavioral health condition, procedures, and treatment under review and are knowledgeable of the issue under review, or of the current, evidence-based clinical guidelines, and novel treatments for the medical or behavioral health condition, disease, treatment, or procedure under review.

Have the clinical expertise to manage the medical or behavioral health condition or disease under review. Individuals who conduct appeal peer review possess a license or certification in a health profession that is of the type and scope that permits them to apply their clinical judgement in consideration of an individual member’s clinical needs to render a utilization review determination.

This individual will play a key role in the direction and execution of the PHP success in Nevada, Texas, Florida, and other markets as indicated related to the delivery of medical services in a population management environment. This medical leader will be responsible for strategically developing and enhancing the existing Medical Management Service Department in the areas of medical policy and procedures, utilization management, peer-to-peer clinical review, pharmacy management, quality of care, quality of service, physician enhancement and development,…