The Medical Director assists senior leadership in planning, directing and coordinating all medical and related activities for CHOICE Health Plans. Participates in implementing standards of medical service and advises senior leadership on medical and administrative questions and policies as they relate to the CHOICE population. Plans for and participates in physician education. Investigates and implements new medical and clinical practices and techniques. Serves as consultant for unusual and difficult medical cases. Actively participates in the QARR/HEDIS Quality Improvement Activities and utilization management of the population.
- Assists in the supervision of medical operations to ensure high quality and cost effective medically necessary services, along with ongoing care management, are provided by assigned staff based on medical standards in home, community and facility-based settings within a capitated reimbursement rate.
- Participates in establishing medical policies; designs and implements advanced care/case management strategies; and communicates, as needed, with providers to ensure effective quality care is being provided.
- Reviews care/case management reports and identifies trends and needs of the program population; collaborates with Medical Management leadership to develop and implement plans to meet needs.
- Provides guidance and consultative services to Utilization Management (UM) and Care Management (CM) staff on issues relating to clinical services, case management, condition management, and health risk assessments. Develops solutions for complex cases, reviews prior authorizations/denial of services, and grievances and appeals. Participates in weekly care management/UM rounds for products, as applicable. Performs audits of other UM/CM physician peer reviewers.
- Provides leadership to the Quality Improvement Program and advises CHOICE leadership on the adoption/enforcement of polices concerning medical services for CHOICE membership.
- Ensures compliance with relevant and applicable federal, state and local laws and regulations. Works with Compliance and Special Investigation Unit on issues related to Fraud, Waste, and Abuse of Medicare/Medicaid services.
- Collaborates with pharmacy services to review PBM activities, review denial of prior authorizations, implement new government program policies and monitor for fraud, waste, abuse of drugs. Educates pharmacists on adherence, what inappropriate prescribing or duplicative services are. Ensures proper communication established between prescribers, MCO and pharmacists for member medication reconciliation/review.
- Ensures that CHOICE and program guidelines are adhered to in measuring adequacy, appropriateness and effectiveness of plan of care; assists in evaluating program and member service policies/procedures to help develops ways to enhance effective delivery of care and member/provider satisfaction.
- Acts as a representative of CHOICE and an advocate for the community through liaison, lecturing and promotional activities. Attends external meetings, seminars, and conferences to promote sharing of expertise and educate consumers and external providers regarding CHOICE service model.
- Establishes and fosters ongoing communication with providers to understand their barriers to delivering quality care; collaborates with providers in discussing options available to help maintain best standards in practice.
- Participates in special projects and performs other duties, as assigned.
- Licensed to practice medicine in New York State required. Board Certification in internal or family medicine preferred.
- Certification in Geriatric Care preferred.
- Minimum five years of experience in clinical medicine, required. Minimum three years of experience in managed care or population health required.
- Prior expertise in geriatrics or HIV medicine preferred.