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Develops and is responsible for the PMC program for meeting Risk contract standards regarding care management, Utilization Management, delegation status and NCQA standards for medical review. The Director of Operations will also lead community efforts to drive utilization management, population health tactic implementation, and regularly represent Pacific Medical Centers with various stakeholders.
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Works with the Landmark Health Medical Director, Director of Health Services, Corporate Director of Health Services, and UM staff in the development and/or implementation of medical management policy, clinical protocols, utilization management guidelines, and quality management programs.
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Experience with EQR processes, CMS guidelines, and state-specific criteria, clinical research, practice guidelines, health care disparities, Medicaid waiver programs, NCQA, EQRO, QIO, and Joint Commission requirements required.
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Remain updated on CMS’ HCC program, medical knowledge and NCQA Technical Specifications as it applies to the HCC, STAR and ACO programs. The Director of Risk Adjustment is responsible and accountable for the performance of a specific region in terms of RAF score for all product lines that risk adjust and quality scores for all product lines.
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Must have a minimum of 5 years clinical experience, beyond residency/fellowship Knowledge of applicable state and federal laws, URAC and NCQA standards a plus, and familiarity with automated processes and computer applications and systems is requiredNo nights, no weekends, not call.
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Experience with NCQA, HEDIS, Medicaid, Medicare, quality improvement, medical utilization management, and risk adjustment. The Regional Medical Director is a key clinical leader within Monogram Health who contributes to the development and oversight of clinical strategies, policies, programs, processes, protocols, guidelines, and operations that drive improved patient health outcomes in conjunction with the Practice Medical Directors to motivate and provide medical direction in pursuit of evidence based and cost effective, quality healthcare.
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Experience with management and/or engagement with national quality organizations, including National Committee of Quality Assurance (NCQA) structure and standards and Health Plan Employer Data and Information Set (HEDIS) and National Quality Forum (NQF) is required.
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NCQA, URAC and/or HEDIS accreditation experience strongly preferred. Director Clinical Services Operations would have a Bachelor's degree in healthcare, business or related field, ten years of experience in a health insurance environment (to include utilization management, clinical intake/customer service, health information management, and/or quality improvement) and five years leadership experience or equivalent combination of education and experience.
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The Credentialing Coordinator independently gathers, conducts and analyzes data/information via the primary source in accordance with the credentialing/privileging standards of all applicable accrediting and regulatory agencies (TJC, NCQA, State, and Federal) as well as the Grady Health System Medical Staff Bylaws and Rules and Regulations and Grady Health System policies and procedures.
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R) Must be knowledgeable of DHCS, CMS, DMHC regulations and NCQA regulatory Population Health standards. Develop, implement and manage all UM processes for continuous and sustained compliance with all applicable state, federal and NCQA regulatory requirements, SCFHP policies and procedures and general business requirements for all lines of business.
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Participates in strategic planning for and evaluation of the Care ManagementThe successful candidate will be an M.D. or D.O. with a current, active, U.S. state medical license and board certified in Gastroenterology, recognized by the American Board of Medical Specialties (ABMS), with recent practice experience in direct patient care (within the past 18 months.
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Provides timely expert medical review for requests to evaluate the medical necessity of services that do not meet utilization review criteria while located in a state or territory of the United States.
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Participates in strategic planning for and evaluation of the Care ManagementThe successful candidate will be an M.D. or D.O. with a current, active, U.S. state medical license and board certified in Surgery - Orthopedics, recognized by the American Board of Medical Specialties (ABMS), with recent practice experience in direct patient care (within the past 18 months.
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Reviews appeals for denied services related to current relevant medical experience or knowledge in accordance with appeal policies, if so delegated. Provides timely peer-to-peer discussions with referring physicians to clarify clinical information and to explain review outcome decisions.
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We are accredited by The Joint Commission and certified as a NCQA Patient-Centered Medical Home Level III.This role is an employment model position in the Harvard Medical Faculty Physicians at Beth Israel Deaconess Medical Center, Inc. (HMFP.
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