Medical Director

• Oversee day-to-day medical management activities, including utilization reviews, appeals and grievances, case consultations, and recommendations
• Develop and maintain medical and departmental policies and procedures supporting utilization management
• Work with the Chief Medical Officer to establish, implement, and monitor resource and cost utilization plans
• Collaborate with medical, quality, compliance, and government-relations leaders to ensure regulatory and accreditation compliance
• Make clinical service determinations based on medical appropriateness and applicable criteria and guidelines
• Deny requests when medically necessary criteria, policy, or appropriateness requirements are not met
• Lead or participate in corporate and community committees, task forces, and project initiatives
• Serve as a subject matter expert in Medical Management and interpret regulatory requirements
• Develop health plan departmental objectives and strategies with senior management
• Coordinate development and annual review of medical policies, procedures, and standards for CMS, Oregon Health Plan, and NCQA requirements
• Participate in credentialing, patient care, quality improvement, pharmacy, departmental, utilization management, and case review meetings
• Support Medical Management staff activities and quality member care coordination
• Optimize member experience and customer satisfaction
• Serve as lead Medical Management liaison to independent physicians and other providers
• Support physician recruitment and credentialing efforts
• Refer appropriate situations to Quality Committee, Corporate Compliance, Fraud & Abuse, or Legal Services
• Ensure compliance with confidentiality and HIPAA requirements
• Participate in rotating weekend on-call coverage for emergent prior authorization requests
• Maintain punctual, regular, and predictable attendance
• Complete required training and perform other duties as assigned

Explore Associate Medical Director at AllCare Health. Review requirements and application details.