Remote Medical Director, Pharmacy

Location: Northern

** Position

Purpose:

** Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit.
* Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities.  
* Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality decision making.  
* Supports effective implementation of performance improvement initiatives for capitated providers.  
* Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members.  
* Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.  
* Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership.  
* Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes.  
* Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals.  
* Participates in provider network development and new market expansion as appropriate.  
* Assists in the development and implementation of physician education with respect to clinical issues and policies.  
* Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components.  
* Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care.  
* Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality.  
* Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment.  
* Develops alliances with the provider community through the development and implementation of the medical management programs.  
* As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues.  
* Represents the business unit at appropriate state committees and other ad hoc committees.  
* May be required to work weekends and holidays in support of business operations, as needed.  
** Education/

Experience:

*** Medical Doctor or Doctor of Osteopathy.
* Utilization Management experience and knowledge of quality accreditation standards preferred.
* Actively practices medicine.
* Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is advantageous.
* Experience treating or managing care for a culturally diverse population preferred.
** License/

Certifications:

*** Board certification in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Association’s Department of Certifying Board Services.
* Certification in Internal or Family Medicine, preferred.
* Current state license as a MD or DO without restrictions, limitations, or sanctions from government programs.

Pay Range: $ - $ per year