Medical Director, Care Management

YOUR RESPONSIBILITIES

• Work to achieve the health optimization performance objectives for care management, including guiding care within our networks, supporting members in obtaining the right care at the right place, identifying opportunities for utilization management (length of stay, re admissions), and supporting STARS, through assuring access to care, affordability, and member satisfaction.
• Provide clinical support for medical management across multiple markets for Bright’s Medicare and Individual and Family Plans
• Actively participate in, and work toward the achievement of target metrics in these domains:
• Population Health Management: Utilization Management, Early Risk Identification
• Network Management: Adequacy, Contracting, OON requests
• Quality: CCIPS Implementation, STARS Optimization
• Clinical Compliance: Appeals & Grievances, FWA monitoring, Compliance reporting
• Act as lead business and clinical liaison to network providers and facilities to support the effective execution of medical services programs
• Provide clinical expertise and business direction in support of medical management programs through participation in clinical team activities: P&T Committee, Quality Committees, Credentialing Committees, Utilization Management Committees, and Joint Operating Committees
• Provide support where clinical expertise is required, including but not limited to reviews of claim determinations, evaluating the accuracy of coding, and consulting on current reimbursement practices for clinical services and procedures
• Consult on the design, build and management of interventions that improve clinical outcomes
• Promote approaches that can improve clinical practice performance while achieving similar or greater clinical quality
• Support the development and execution of repatriation policies and procedures to transition members from out-of-network care settings to a clinically appropriate in-network care setting
• Support collaborative relationships with physicians, large provider groups, hospitals, other facilities and ancillary providers
• Support Provider Education efforts

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

• Post-graduate experience in direct patient care
• Previous leadership experience in a clinical oversight role
• MD or DO and Board Certification in an ABMS specialty
• Unrestricted Medical License

LICENSURE

• Unrestricted and active medical license