Medical Director - Multiple Openings/REMOTE

Summary of Position

• Manage the daily clinical operation and administration of a Medical Management Department or function to support improved utilization results across the spectrum of medical specialties.
  
• Provide clinical leadership both internally and externally.
  
• Serve as an essential liaison among Senior Management, Plan staff, contracted providers, vendors, and membership to promote and improve communication and operations areas of medicine including Internal Medicine, OB/GYN, Psychiatry, Ambulatory Medicine, Emergency Medicine and Radiology.
  
• Carry out assigned programs to ensure the delivery of quality medical care to the EmblemHealth membership and compliance with contractual obligations and standards; assist in the development and implementation of new policy and programs as needed.
  
• Maximize operational effectiveness and oversight of assigned functions, ensuring regulatory compliance and accreditation with Department of Health, Department of Insurance, CMS, NCQA, and URAC standards.
  
• Provide services per the NYCE contract.

Principal Accountabilities

• Manage use of medical resources for inpatient and outpatient services including Internal Medicine, OBGYN, Neurology, Surgery, Pediatrics, Emergency Medicine or Psychiatry.
  
• Determine medical appropriateness through the application of clinical criteria; perform case management review; and participate in the clinical appeals process.
  
• Sole authority and responsibility for issuing clinical adverse determinations based on medical necessity.
  
• Conduct medical rounds, attend Medical Director meetings and participate in the inter-rater reliability process.
  
• May also perform peer clinical reviews as needed.
  
• Establish and maintain continuity in the planning, development and implementation of policies, operational processes, workflows required to execute organizational strategies and to assure consistency in process application throughout Care Management.
  
• Validate and monitor adherence to implemented policies, procedures, workflows and processes: identify, recommend and implement improvement initiatives accordingly.
  
• Generate methods to develop and improve the overall delivery and performance of the department.
  
• Implement process improvements in a timely manner.
  
• Deal effectively with and lead others throughout Company structure.
  
• Support other areas in implementing cross-departmental changes.
  
• Make sound decisions based on all available data.
  
• Determine medical appropriateness through the application of clinical criteria and perform case management review.
  
• Demonstrate familiarity with high-risk populations, community settings and care of medical patients.
  
• Anticipate and identify key source information to analyze problems clearly and determines creative solutions.
  
• Provide thought leadership to articulate and help build an effective and efficient medical delivery program.
  
• Identify trends, problems and opportunities, conduct root cause analysis.
  
• Implement action plans in an effective and efficient manner aimed at promoting goals/resolving barrier issues.
  
• Strive to improve efficiencies of key operational areas.
  
• Assist with contract negotiations as necessary.
  
• Represent Care Management in interdepartmental committees designed to meet organizational goals.
  
• Develop annual goals and oversight of assigned department/function.
  
• Support Senior Medical Directors in communications with internal and external organizational goals; ensure a high level of customer satisfaction (members, vendors, providers, regulators, accreditation agencies, peers and employees).
  
• Chair or participate on committees as requested.
  
• Regular attendance is an essential function of the job. Perform other duties as assigned or required.