UM Medical Director - Medicaid

Oklahoma City, OK

full-time
Non clinical

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.
  • 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. Utilizes the services of medical and pharmacy consultants for reviewing complex cases and medical necessity appeals. Participates in provider network development and new market expansion as appropriate.
  • 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.

Requirements:

MD or DO, BC preferable in a primary care specialty (Internal Medicine, Family Practice, Pediatrics or Emergency Medicine). Previous experience within a managed care organization is preferred. Experience treating or managing care for a culturally diverse population preferred.

Current OK license without restrictions.


Posted April 5, 2021