In support of the CMO, the Associate Medical Director is responsible for the administration of procedures, protocols, and standards regarding the efficiency and quality of the health care delivered to Network Health (NH) members. This individual will be chair of at least 3 committees related to quality and accreditation.
Location: Candidates must reside in the state of Wisconsin for consideration. This position is eligible to work at your home office (reliable internet is required). Travel is required occasionally for the position.
Hours: 1.0 FTE, 40 hours per week, 8am - 5pm Monday through Friday, weekend coverage required on rotational basis.
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Job Responsibilities:
- Assist the CMO with monitoring availability, appropriateness, and necessity of care rendered by participating providers and by out-of-plan providers
- Participate in oversight and clinical decision making of the UM program, including but not limited to rendering denial determinations for services not considered medically necessary or experimental/investigation/unproven in accordance with regulatory and quality standards
- Contribute to the development of quality care guidelines, internal peer review procedures, and the evaluation of medical care evaluation studies under the NHP quality assurance programs
- In coordination with the CMO and Directors of Health Management and QI and Disease Management, share responsibility for the development and continued evaluation of utilization review and quality assessment processes
- Provide medical consultation as requested for:
- Medical/legal issues
- Member grievance procedures
- Development and implementation of new benefit packages and the interpretation of covered benefits in NHP contracts
- Medical issues related to contract negotiations with health care providers
- Determining if services to members/enrollees meet medical criteria
- Promote positive relationship between NHP and medical community
- Serve as liaison between NHP and providers regarding matters of medical policy and medical administration
- Serve as spokesperson for NHP in the medical community and maintains appropriate contact with professional health care organizations
- Participates in the ongoing recruitment of plan physicians
- Respond to physicians and other provider inquiries and complaints within established guidelines of the Executive Committee and Board of Directors
- Assist in the development of appropriate medical guidelines and parameters for claims review
- Assist in the training of NHP staff on matters relating to medical guidelines
- Oversight responsibility for monitoring and evaluating Medicare Special Needs Plan Model of Care effectiveness
- Perform second level review of provider appeals and disputes
- Serve on committees as coordinated with the CMO
- Assist in strategic planning targeted towards plan growth initiatives
Job Requirements:
- Doctor of Medicine (MD or DO), licensed in the state of Wisconsin without restriction
- Member in good standing of the local medical community
- An active practitioner of medicine in the NHP service areas
- Must possess a thorough knowledge of the health professional and facilities and standards of practice of medicine in NHP's service area
- Must possess sufficient medical experience and other experience, including knowledge of the Medicare program, to review organization determinations involving medical necessity
- Board certified in an ABMS medical specialty required
Network Health is an Equal Opportunity Employer