Medical Director - Health Plan - Part-time
Baylor Scott & White Health
Scott & White Clinic
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The Health Plan Medical Director (part-time) is responsible for managing health plan medical costs and assuring appropriate health care delivery for plans and members. Is accountable to provide professional leadership and direction in the utilization/cost management (UM) and clinical quality improvement (QI) of the health plan, as measured by benchmarked UM and QI goals. Works collaboratively as a clinical resource to other plan functions that interface with medical management such as provider relations, member services, benefits, claims management, etc. Carries out medical policies at the health plan consistent with NCQA and other regulatory bodies.WHAT IS EXPECTED (Essential Functions): - Identify opportunities for corrective action plans to address issues and improve plan and network managed care performance.
- Collaborate with Provider Networks and Medical Director team in creating and maintaining programs that incentivize providers to achieve selected utilization/cost and quality outcomes.
- Participate in the retrospective review and analysis of Plan performance from summary data of paid claims, encounters, authorization logs, compliant and grievance logs, and other sources.
- Provide periodic written and verbal reports and updates as required in the Quality Management Program description, the Annual QI Work Plan.
- Assure plan conformance with legal and regulatory requirements; support NCQA qualification activities, including site visits and response to accrediting and regulatory agency feedback.
- Support pre-admission review, utilization management, concurrent and retrospective review process and case management.
- Participate in risk management, claims administration, pharmacy utilization management, catastrophic case review, outreach programs, HEDIS reporting, site visit review coordination, triage, nutrition service review, provider orientation, credentialing, profiling, etc.
- Conduct quality improvement and outcomes studies as directed by the state and federalregulatory agencies, the Quality Management Committee, Medical Advisory Committee, Peer Review Committee, and management.
- Support grievance process, as led by Chief Medical Offices, insuring a fair outcome for all members.
- Monitor member and provider satisfaction survey results and implements changes as needed to increase satisfaction and assure that satisfactory relationships are maintained between network and plan participants.
- May be asked to chair various Health Plan committees, such as Quality Management subcommittees on Peer Review or Credentialing.
- Promote wellness and ensure programs of prevention, education and outreach to members and providers consistent with company's mission, vision, and values.
- Perform and oversees in-service staff training and education of professional staff.
- Contribute to the development of strategic planning for existing and expanding business; recommend changes in program content in concurrence with changing markets and technologies.
- Participate in key marketing activities and presentations, as necessary, to assist the marketing effort.
- Performs other position appropriate duties as required in a competent, professional, and courteous manner as directed by management.
KNOWLEDGE, SKILLS, and ABILITIES: - 5 years of clinical experience in the practice of medicine, 2 of which have been in medical and/or health administration, preferably in a managed care setting.
- 3 years of management and/or clinical experience in a managed care environment.
- Management skills to meet the organizational goals.
- Must possess excellent communications skills to interface with providers, staff, and management.
- Knowledge of medical, quality improvement and UM practices in a managed care environment.
- Knowledge of regulatory and accreditation agencies and requirements.
- Able to manage multiple priorities and deadlines in an expedient and decisive manner.
- Able to manage difficult peer situations arising from medical care review.
- Appreciation of cultural diversity and sensitivity towards target population
- Up-to-date knowledge of new information and technologies in medicine, and their application to Health Plans, as well as computer applications, including productivity tools and Care Management Platforms.
- Must be available during normal working hours to make coverage decisions. Additional after hours availability may be required to review emergently or urgently needed services.
- Doctorate Degree Required
- 5+ years of experience
- Unrestricted License Texas as a Doctor of Medicine or a Doctor of Osteopathy.
- Certified in a recognized medical specialty as recognized by the American Board of Medical Specialists (ABMS).
The largest not-for-profit health care system in Texas, Baylor Scott & White Health was born from the 2013 combination of Baylor Health Care System and Scott & White Healthcare. Known for exceptional patient care for more than a century, Baylor Scott & White Health includes 44 hospitals, more than 500 patient care sites, 6,000 affiliated physicians and 34,000 employees as well as the Scott & White health plan. Baylor Scott & White Health exists to serve all people by providing personalized health and wellness through exemplary care, education and research as a Christian ministry of healing.
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