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Growing MLTC, FIDA, and Medicare Advantage Plan
Well known Healthcare organization in New York
About Our Client
Our client is a well know Healthcare organization with MLTC, FIDA, and Medicare Advantage Plans.
- Assists in the supervision of medical operations to ensure high quality and cost effective medically necessary services, along with ongoing care management, are provided by assigned staff based on medical standards while abiding with contract relationships in home, community and facility-based settings within a capitated reimbursement rate.
- Participates in establishing medical policies; designs and implements advanced care/case management strategies; and communicates, as needed, with providers to ensure effective quality care is being provided.
- Reviews care/case management reports and identifies trends and needs of the program population; collaborates with Medical Management leadership to develop and implement plans to meet needs.
- Provides guidance and consultative services to Utilization Management (UM) and Care Management (CM) staff on issues relating to clinical services, case management, condition management, and health risk assessments. Develops solutions for complex cases, reviews prior authorizations/denial of services, and grievances and appeals. Participates in weekly care management/UM rounds for products, as applicable.
- Contributes to the Quality Improvement Program and advises governing authority on the adoption/enforcement of polices concerning medical services for the membership.
- Ensures compliance with relevant and applicable federal, state and local laws and regulations. Works with Compliance and Special Investigation Unit on issues related to Fraud, Waste, and Abuse of Medicare/Medicaid services.
- Collaborates with pharmacy services to review PBM activities, review denial of prior authorizations, implement new government program policies and monitor for fraud, waste, abuse of drugs. Educates pharmacists on adherence, what inappropriate prescribing or duplicative services are. Ensures proper communication established between prescribers, MCO and pharmacists for member medication reconciliation/review.
- Ensures that program guidelines are adhered to in measuring adequacy, appropriateness and effectiveness of plan of care; assists in evaluating program and member service policies/procedures to help develops ways to enhance effective delivery of care and member/provider satisfaction.
- Analyzes utilization data or other data to identify deficits or needed interventions. Collaborates with UM leadership to develop and implement strategies designed to achieve desired outcomes. Monitors impact of strategies to ensure improved clinical resource allocation, utilization and referral patterns, patient satisfaction, and clinical outcomes.
- Acts as a representative of the plan and an advocate for the community through liaison, lecturing and promotional activities. Attends external meetings, seminars, and conferences to promote sharing of expertise and educate consumers and external providers regarding our client's service model.
- Establishes and fosters ongoing communication with providers to understand their barriers to delivering quality care; collaborates with providers in discussing options available to help maintain best standards in practice.
- Helps supervise, evaluate and provide feedback to medical management staff regarding their activities effecting the membership.
- Participates in special projects and performs other duties, as assigned.
The Successful Applicant
The Medical Director will have the following:
- Licensed to practice medicine in New York State required
- Board Certification required
- Certification in Geriatric Care preferred
- Minimum five years of experience in clinical medicine, including geriatrics or HIV population, required
- Minimum three years of medical management experience required
- Administrative and/or management experience required
- Managed care experience preferred.
- Excellent communication and presentation
What's on Offer
Commensurate with skills and abilities