Associate Medical Director

The Associate Medical Director plays a pivotal role in supporting the medical management staff to ensure timely and consistent medical decisions for our members and providers. As a key member of our team, you will be responsible for various clinical operations tasks, including clinical case reviews, medical necessity determinations, peer-to-peer conferences, appeal review, and policy adherence.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Conduct timely clinical case reviews within your board-certified specialty.
Initiate physician-to-physician calls to gather pertinent medical information for making medical necessity determinations.
Determine medical necessity for grievance and appeals cases.
Ensure the consistent application of medical policies in medical necessity decisions.
Bring to the attention of supervisors any case review decisions requiring Medical Director review or policy interpretation.
Work adhering to US regulatory and Quality System requirements (21 CFR 820, etc).
This position assumes and performs other duties as assigned.

QUALIFICATIONS

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions:

Superior knowledge of utilization management guidelines, plan benefit design, and medical necessity criteria
Knowledge of health care delivery systems, statistical review skills, and data management skills
Knowledge of ambulatory and inpatient utilization patterns/efficiency
Demonstrable skills in successful managing for agreement
Knowledgeable of State of Texas Department of Insurance (TDI) regulations, TDH and federal regulations governing claims payment, and HIPAA regulations.
Excellent verbal and written communication skills.
Strong computer skills including working with Google applications.
Ability to communicate with all levels of staff including physicians and Executive Management.
Required to manage laterally and upward, as well as downstream.

EDUCATION and/or EXPERIENCE

At least five (5) years of experience in utilization management (managed care experience preferred). Additional background in health care delivery systems, statistical review skills, and data management skills preferred.

CERTIFICATES, LICENSES, REGISTRATIONS

MD degree and Board certification in a medical specialty.

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this Job, the employee is regularly required to sit; use hands to handle or feel; talk; and hear.
Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.
The noise level in the work environment is usually: Mild
For this position the percentage of expected Travel is: 5% of the time