The per diem Medical Director provides medical leadership and has responsibility for Health-care-related management oversight activities including Utilization Management, Network Management, Quality Improvement. Responsibilities include facilitation of evidence-based and cost-effective professional and institutional services to our membership through oversight of day to day utilization management operations of clinical and non-clinical leaders to ensure compliance with legal and requirements. May participate in various committees to support performance improvement, improve quality of medical care and the physician and patient experience . Engages physicians to promote relationships and alignment with organizational goals.
Collaborates with Chief Medical Officer (CMO) and Senior Leadership to implement strategic plans to achieve the company mission and vision.
Collaborates with director of clinical pharmacy services to support utilization of most clinically and cost effective medications including infusions, injections and generics.
Acts as clinical support for team to reduce inappropriate emergency department and urgent care utilization.
Collaborates with team members supporting chronic disease programs as needed.
Collaborates with team members of programs to achieve preventative care targets as needed.
Collaborates with contracting, medical management and leadership on incentives, metrics, clinical programs to improve the quality of care provided to our members along with decreasing costs.
Oversees the clinical decision making and Utilization Management/Case Management/Disease Management programs with a focus on adherence to best practices and value-based care.
Oversees concurrent review team with attention to average daily census and length of stay in contracted and non-contracted hospital facilities, Long-Term Acute Care (LTAC) facilities, Sub-Acute facilities, Skilled Nursing Facilities and Rehabilitation facilities.
Oversees elective surgery costs, volume and facilities.
Oversees medical specialty utilization and costs.
Oversees patient steerage to preferred facilities.
Engages with network physicians with regard to the cost, clinical appropriateness and authorizations.
Oversees the management of tertiary care referrals and utilization.
May participate in GNP and MCMF committees as needed or directed (e.g. Quality, utilization management, credentialing, etc.)
Supports the high-risk patient care team in their management of complex or high-cost members, end-of-life care as well as appropriate utilization of hospice and palliative care services.
Promotes system-wide efforts to improve the quality of care to all patients through physician education, relationships, and direction to appropriate clinical support.
Participates in peer review, credentialing, QI department and grievances/appeals and HCC coding initiatives and implementation of best practices as needed.
Assists in managing and maintaining an effective network through relationship-building and educating IPA physicians.