Associate Medical Director

In support of the CMO, the Associate Medical Director is responsible for the administration of procedures, protocols, and standards regarding the efficiency and quality of the health care delivered to Network Health (NH) members. This individual will be chair of at least 3 committees related to quality and accreditation.

Location:

Candidates must reside in the state of Wisconsin for consideration. This position is eligible to work at your home office (reliable internet is required). Travel is required occasionally for the position.

Hours:

1.0 FTE, 40 hours per week, 8am - 5pm Monday through Friday, weekend coverage required on rotational basis

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Job Responsibilities:

Assist the CMO with monitoring availability, appropriateness, and necessity of care rendered by participating providers and by out-of-plan providers

Participate in oversight and clinical decision making of the UM program, including but not limited to rendering denial determinations for services not considered medically necessary or experimental/investigation/unproven in accordance with regulatory and quality standards

Contribute to the development of quality care guidelines, internal peer review procedures, and the evaluation of medical care evaluation studies under the NHP quality assurance programs. In coordination with the CMO and Directors of Health Management and QI and Disease Management, share responsibility for the development and continued evaluation of utilization review and quality assessment processes

Provide medical consultation as requested for:

Medical/legal issues

Member grievance procedures

Development and implementation of new benefit packages and the interpretation of covered benefits in NHP contracts

Medical issues related to contract negotiations with health care providers

Determining if services to members/enrollees meet medical criteria

Promote positive relationship between NHP and medical community

Serve as liaison between NHP and providers regarding matters of medical policy and medical administration

Serve as spokesperson for NHP in the medical community and maintains appropriate contact with  professional health care organizations

Participates in the ongoing recruitment of plan physicians.

Respond to physicians and other provider inquiries and complaints within established guidelines of the Executive Committee and Board of Directors Assist in the development of appropriate medical guidelines and parameters for claims review

Assist in the training of NHP staff on matters relating to medical guidelines

Oversight responsibility for monitoring and evaluating Medicare Special Needs Plan Model of Care effectiveness

Perform second level review of provider appeals and disputes

Serve on committees as coordinated with the CMOAssist in strategic planning targeted towards plan growth initiatives

Job Requirements:

Doctor of Medicine (MD or DO), licensed in the state of Wisconsin without restriction

Member in good standing of the local medical community. An active practitioner of medicine in the NHP service areas

Must possess a thorough knowledge of the health professional and facilities and standards of practice of medicine in NHP’s service area

Must possess sufficient medical experience and other experience, including knowledge of the Medicare program, to review organization determinations involving medical necessity

Board certified in an ABMS medical specialty required

Network Health is an Equal Opportunity Employer

Job Summary

Requisition Number: ASSOC
002310

Job Category:
Health Management

Schedule:

Full-Time