National Medical Director Utilization Management u2013 Quality Management

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National Medical Director Utilization Management – Quality Management *Employed*Can work remote*Growing organization*Excellent compensation package and full benefitsrnJob Description: rnrnLeads, develops, directs, and implements clinical and non-clinical activities that impact health care quality cost and outcomes.rnIdentifies and develops opportunities for innovation to increase effectiveness and quality.rnProvide clinical expertise across the enterprise for various functions.rnResponsible for corporate and medical policy interpretation, recommendation, and review within recognized areas of responsibility.rnAdvise and collaborate in the develop of clinical programs.rnProvide clinical support and participate in utilization management, quality management and care management programs in respective area and identify opportunities for improvement and efficiency.rnAssist with the design, development, implementation and assessment of preventative care, quality, and health enhancement programs that support the appropriate use of clinical resources in the delivery of consistent high- quality medical care to drive HEDIS metric compliance.rnProvide clinical leadership for medical necessity reviews, application of clinical guidelines in decision making and for health promotion and education programsrnAssist is establishing corporate and regional programs to enhance quality of care reduce medical costs and achieve positive health outcomes.rnServes as a clinical resource and subject matter expert to both clinical and non – clinical staff.rnPerform clinical reviews and conduct peer to peers.rnConduct discussions with physicians in the network regarding HEDIS metrics, medical policies, utilization management, claims editing, use of resources and quality.rnPerform clinical data review of HEDIS compliance and develop strategic initiatives to increase patient compliance.rnPerform high dollar claims and complex case reviews.rnParticipate in inter-rater reliability activities.rnParticipate in committees and workgroups to achieve department and corporate objectives.rnParticipate in health plan Joint Operating Committees.rnrn rnQualifications:rnrnDoctorate from an accredited school of medicine (M.D.) or osteopathy (D.O.) required.rnSeven (7) years of clinical experience or any combination of education and experience, which would provide an equivalent background.rnTwo (2) years of previous medical director experience working for a health plan, medical group, or hospital in a utilization management, quality management or medical management preferred.rnCurrent unrestricted state of Nevada, Arizona, Oregon, Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) license or ability to obtain license.rnBoard certified or board eligible and working towards certification in a specialty approved by thernrnAmerican Board of Medical Specialists or the American Board of OsteopathyrnrnrnCertification in Utilization Review and Health Care Quality & Management is preferred.rnKnowledge of HEDIS, NCQA, and CMS Stars ProgramsrnAbility to effectively communication with external physicians and organizationsrnProven leadership, problem solving and the ability to manage multiple priorities.rnRequires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.rnResults oriented and the ability to take ownership for initiatives and collaborate with cross-functional teams to achieve department and corporate goals.rnDemonstrate skill with Microsoft Office Suite and web-based program.rnUnderstanding of health plan and medical group functions related to utilization, care, as well as HEDIS/STAR s and NCQA. Familiarity with CMS regulations and standards.rnBasic knowledge of evidence-based clinical decision support guidelines (Inter Qual/Milliman).rnBasic knowledge of CPT coding and guidelines and how they relate to quality data capture.rnOther related skills and/or abilities may be required to perform this job.rnrnTo apply and learn more about this position please email a copy of your cv to ****.,validThrough:2023-07-01T23:59:59-05:00,employmentType:FULL_TIME,directApply:true,hiringOrganization:{@type:Organization,name:**MEMBERS ONLY**SIGN UP NOW***.},identifier:{@type:PropertyValue,name:**MEMBERS ONLY**SIGN UP NOW***.,value:MD_4503},jobLocation:{@type:Place,address:{@type:PostalAddress,addressCountry:US,addressLocality:Las Vegas,addressRegion:Nevada}}}

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