Medical Director

About This Role

Manage the daily clinical operations and administration of a Medical Management Department, providing clinical leadership internally and externally to improve utilization results across various medical specialties. Ensure delivery of quality medical care and compliance with contractual obligations and standards.

Responsibilities

• Manage use of medical resources for inpatient and outpatient services including Internal Medicine, OBGYN, Neurology, Surgery, Pediatrics, Emergency Medicine or Psychiatry
• Determine medical appropriateness through the application of clinical criteria; perform case management review; and participate in the clinical appeals process
• Exercise sole authority and responsibility for issuing clinical adverse determinations based on medical necessity
• Conduct medical rounds, attend Medical Director meetings and participate in the inter-rater reliability process
• Establish and maintain continuity in the planning, development and implementation of policies, operational processes, and workflows
• Validate and monitor adherence to implemented policies, procedures, workflows and processes; identify, recommend and implement improvement initiatives
• Generate methods to develop and improve the overall delivery and performance of the department
• Provide thought leadership to articulate and help build an effective and efficient medical delivery program
• Identify trends, problems and opportunities, conduct root cause analysis, and implement action plans
• Assist with contract negotiations as necessary and represent Care Management in interdepartmental committees

Requirements

• MD or DO degree and Board certification
• Active New York or Connecticut license or certification to practice medicine without restriction
• 10+ years of relevant, professional work experience
• 5+ years of clinical practice
• Administrative experience on a hospital committee, in a medical group or for an insurer
• Knowledge of clinical practice of medicine, health care delivery systems, utilization methods and treatment protocols
• Knowledge and understanding of managed care principles, industry evolution, physician reimbursement, and human resource management
• Experience conducting evidence-based treatments in group and individual modalities, especially for psychiatric treatment
• Considerable independent decision making with physicians, members, subordinates, other departmental leaders and external vendors, regulatory and accreditation agencies
• Excellent communication skills (verbal, written, presentation, interpersonal)

Qualifications

• MD or DO degree. Board certification is required
• 10+ years of relevant, professional work experience; 5+ years of clinical practice

Certifications