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Medical Director - Health Plan
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Full-time
- 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.
- Participate in the retrospective review and research of Health Plan performance from summary data of paid claims, encounters, authorization logs, compliance 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; help NCQA qualification activities, including site visits and response to accrediting and regulatory agency feedback.
- Help pre-admission review, utilization management, concurrent and retrospective review process and case management.
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