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Medicaid Program Medical Director MD/DO

Company: ARRA Group
Location: Killeen
Posted on: May 15, 2022

Job Description:

Position: Medicaid Program Medical Director MD/DOEmployment Type: Full TimeLocation: Killeen, TXSalary: $300,000-$330,000 + Full Suite of BenefitsHiring Organization: Not-for-Profit -Healthcare SystemTop 10% High-Performing Health System is Seeking Experienced Medicaid DirectorOne of US News and World Report's most awarded hospitals needs a seasoned Medical Director for their Medicaid program. This position will collaborate with others across the facility's leadership team to improve health outcomes, reduce healthcare disparities and improve health equity. The Medical Director will serve as a clinical leader for groups dedicated to the concurrent review, prior authorization, case management, and clinical coverage review.As one of the largest not-for-profit medical systems in the US, the Medicaid Program Medical Director MD/DO provides medical interpretation and decisions about the appropriateness of services provided by other healthcare professionals in compliance with review policies, procedures, and performance standards. An ideal candidate will be responsible for leading the organization's efforts to achieve excellence in healthcare affordability, quality, member experience, and improved population and member outcomes. -Responsibilities of the Medicaid Program Medical Director MD/DO:

  • ------Collaborate with senior leaders in efforts that enhance the quality of care delivery, improve outcomes, and improve the value delivered to our members
  • Partner with Provider Networks and Medical Director Health Plan team in creating and maintaining programs that incentivize providers to achieve selected utilization/cost and quality outcomes
  • Act as a liaison with physicians, organized hospital administrators, and medical service companies that will serve as a means for providing education and resolving utilization review issues
  • Perform conversations regarding member plan of care
  • Create plans for outcome studies and provides direction to participants
  • Promote wellness programs of prevention, education, and outreach to members and providers consistent with the company's Mission, Ambition, and Values
  • Monitor member and provider satisfaction survey results and implement changes as needed
  • Complete medical necessity prepayment, pre-certification, and other claim reviews
  • Provide repayment, pre-certification, and further claim reviews according to URAC/NCQA standards and Department of Insurance regulations
  • Support pre-admission review, utilization management, the concurrent and retrospective review process, and case management
  • Determine whether requested services requested levels of care, and/or requested site or service should be authorized
  • Identify opportunities for corrective action plans to address issues and improve plan and network managed care performance
  • Execute and review statistical reports relating to patterns of care on hospital utilization and practice patterns of physicians
  • Assist in the development, implementation, and administration of corporate medical policies
  • Create and implement utilization/cost management (UM) and clinical quality improvement (QI) benchmarks
  • Provide periodic written and verbal reports and updates as required in the Quality Management Program Description, the Annual QI Work Plan
  • Conduct quality improvement and outcomes studies as directed by the state and federal regulatory agencies, the Quality Management Committee, Medical Advisory Committee, Peer Review Committee, and management
  • Plan functions that interface with medical management, such as provider relations, member services, benefits, claims management, etc
  • Assure plan conformance with legal and regulatory requirements
  • Carry out medical policies at the health plan consistent with NCQA and other regulatory bodies
  • Work effectively with appropriate company areas in enhancing our acceptability to regulatory accreditation bodies such as HIPPA, HEDIS, etc.
  • 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, etcRequirements for the Medicaid Program Medical Director MD/DO
    • Doctorate (DO) in Osteopathy, Doctor of Medicine (MD) -
    • Unrestricted Texas Doctor of Medicine or Osteopathy License
    • Certified by the American Board of Medical Specialists (ABMS)
    • 5+ years of clinical patient experience required
    • 2+ years of Medical Management industry experience preferred
    • Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or Commercial health insuranceWhy You'll Love It:
      • Competitive Salary and complete benefits package
      • Benefits include: Immediate eligibility for health and welfare benefits, 401(k) savings plan with dollar-for-dollar match up to 5%, Tuition Reimbursement, and PTO accrual beginning Day 1
      • Excellent area schools and higher education options -
      • U.S. News & World Report Recognized Most Awarded Not-for-Profit Health System

Keywords: ARRA Group, Killeen , Medicaid Program Medical Director MD/DO, Executive , Killeen, Texas

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