Desired Skills & Experience
* Requires M.D. or D.O.;
* Board certification approved by the American Board of Medical Specialties required where applicable to duties being performed required.
* 10 years of clinical experience or any combination of education and experience, which would provide an equivalent background.
* Must possess an active unrestricted medical license to practice medicine or a health profession. Unless expressly allowed by state or federal law, or regulation, must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US military base, vessel or any embassy located in or outside of the US.
* Responsible for the administration of medical services for company health plans including the overall medical policies of the business unit to ensure the appropriate and most cost effective medical care is received and for the day-to-day management of medical management staff. Primary duties may include, but are not limited to:
* Interprets existing policies and develops new policies based on changes in the healthcare or medical arena.
* Leads, develops, directs and implements clinical and non-clinical activities that impact health care quality cost and outcomes.
* Identifies and develops opportunities for innovation to increase effectiveness and quality.
* Serves as a resource and consultant to other areas of the company, may chair or serve on company committees, may be required to represent us to external entities and/or serve on external committees, conduct peer clinical and/or appeal case reviews and peer to peer clinical reviews with attending physicians or other ordering providers to discuss review determinations, provides guidance for clinical operational aspects of the program.
* Supports the medical management staff ensuring timely and consistent responses to members and providers.