ColumbusRecruiter Since 2001
the smart solution for Columbus jobs

Medical Director

Company: Wellcare Health Plans
Location: Columbus
Posted on: November 11, 2019

Job Description:

This position is contingent upon the bid award in the state of Ohio to WellCare Health Plans, Inc.Oversees clinical direction of medical services and quality improvement functions at the health plan level. Provides medical management leadership for the health plan and, as applicable, manages all major clinical and quality program components under health plan operations. Oversees medical coordination required for effective utilization and quality management of the health plan network. Functions as medical leadership for effective care integration of WellCare pharmacy operations, utilization/case/disease Management activities, quality improvement activities, and provider relations functions.Reports to: State PresidentDepartment: Executive StateLocation: OhioEssential Functions:Collaborates with the organization's senior leadership to ensure medical compliance with all customer, regulatory, and accreditation requirements for clinical services.Provides current medical expertise and direction for clinical policies, procedures and programs.As required by business and operational priorities, establishes professional working relationships with providers and provider organizations to support the development of the highest possible provider partnerships.Manages day-to-day quality improvement and medical management activities.Establishes and is accountable for health plan utilization, OS applications and quality outcomes.Assures all internal and vendor medical review activities conform to company protocols, customer requirements, and professional standards.Ensures adherence to assigned budget accountabilities.Works closely with other medical directors and clinical services staff to attain and/or maintain compliance with company, customer, accreditation and regulatory requirements.Provides clinical expertise needed to effectively and efficiency resolve complex, controversial and/or unique administrative circumstances.Provides clinical guidance for sales, marketing, legal, regulatory affairs, financial, operational, and related business activities.As requested and needed, provides expert medical education, consultation, and supervision for the clinical staff.Provides medical leadership for development and attainment of the organization's goals.Support provider relations and risk contracting through education, provider visits and problem resolutionCollaborates with corporate care management to establish and implement clinical programs to support and meet care management goalsManages the application of all clinical aspects of the Credentialing Program, Credentialing Committee and Peer Review activities at the state level.Shares responsibility for quality improvement and accreditation initiatives in the assigned market(s)Develops value propositions for clinical programs through quantitative analytics, ROI and evidence-based dataInitiates dialogue with providers, as necessary, to resolve differences in opinions concerning utilization management. Reviews and makes determinations regarding provider appeals.Ensure compliance with federal, state and NCQA standardsOversees provider education regarding pharmacy, utilization, quality improvement and responsible health care expenditures to improve clinical outcomesEstablishes and maintains relationships with key stakeholders in partnership with the market leadershipProvides medical accountability in fulfilling the company's compliance with customer audits and reports, and accreditation surveys.Performs other duties as assigned. Additional Responsibilities:Candidate Education:Required A Doctor in Medicine (MD) or D.O. from an accredited school of medicine recognized by national medical regulatory bodies in the United States Candidate Experience:Required 5 years of experience in direct patient careRequired Other Substantial experience and expertise in the development of medical policies, procedures and programsRequired Other Demonstrated success implementing utilization and quality improvement strategies /techniques and experience with physician behavior modificationPreferred Other Qualifications to perform clinical oversight for the services provided by the health plan to include but not limited to: Education, training or professional experience in medical or clinical practicePreferred Other Past participation in a managed care UM committee Candidate Skills:Advanced Ability to communicate and make recommendations to upper managementAdvanced Ability to effectively present information and respond to questions from families, members, and providersAdvanced Ability to create, review and interpret treatment plansAdvanced Demonstrated leadership skillsAdvanced Ability to work in a fast paced environment with changing prioritiesAdvanced Demonstrated interpersonal/verbal communication skillsAdvanced Demonstrated organizational skillsAdvanced Demonstrated ability to deal with confidential informationAdvanced Ability to represent the company with external constituentsAdvanced Demonstrated negotiation skillsAdvanced Ability to influence internal and external constituentsAdvanced Other Ability to remain calm under pressureAdvanced Other Must be able to apply medical knowledge and principles to business challenges in order to achieve significant member, business, and quality outcomesAdvanced Other Must be detail-oriented and have a "hands-on" approachAdvanced Other Clear understanding of the managed care field and managed care operating components, with emphasis on clinical management of health services, particularly within an integrated managed care modelAdvanced Other Clear understanding of regulatory systems and processes that affect managed care health system Licenses and Certifications:Required An unrestricted and current license to practice medicine in the state of employement (or the ability to obtain one)Required Board Certification Technical Skills:Required Intermediate Microsoft ExcelRequired Intermediate Microsoft WordRequired Intermediate Microsoft PowerPointRequired Intermediate Microsoft VisioRequired Intermediate Microsoft Outlook Languages:About usHeadquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses primarily on providing government-sponsored managed care services to families, children, seniors and individuals with complex medical needs primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, as well as individuals in the Health Insurance Marketplace. WellCare serves approximately 5.5 million members nationwide as of September 30, 2018. WellCare is a Fortune 500 company that employs nearly 12,000 associates across the country and was ranked a "World's Most Admired Company" in 2018 by Fortune magazine. For more information about WellCare, please visit the company's website at EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.

Keywords: Wellcare Health Plans, Columbus , Medical Director, Executive , Columbus, Ohio

Click here to apply!

Didn't find what you're looking for? Search again!

I'm looking for
in category

Other Executive Jobs

Interim FP&A Manager - Columbus
Description: Ref ID: 03350-9502270384Classification: Interim FP A ManagerCompensation: DOEManagement Resources is hiring talented FP A Managers to join the senior/management level consulting practice of Robert Half (more...)
Company: Robert Half Management Resources
Location: Columbus
Posted on: 11/22/2019

Business Development Manager - REMOTE
Description: Business Development Manager - REMOTE br My long time client is seeking a Business Development Manager for their awesome team Please review the requirements below and let me know what you think. If (more...)
Company: CyberCoders
Location: Columbus
Posted on: 11/22/2019

Account Manager
Description: We are looking for sales account managers, willing to get a state insurance license or who are already licensed. br br New to Life Insurance Sales You've come to the right place. br You will be (more...)
Location: Columbus
Posted on: 11/22/2019

Senior Construction Project Manager
Description: Job Description Russ Hadick Associates has partnered with a Columbus, Ohio area client to help them search and qualify candidates for their Senior Project Manager
Company: Russ Hadick & Associates, Inc.
Location: Columbus
Posted on: 11/22/2019

Maintenance Manager
Description: Birchwood Foods is now hiring a Maintenance Manager. br br As the Maintenance Manager you are responsible for managing all aspects of the maintenance department. This includes managing and training (more...)
Company: Birchwood Foods
Location: Columbus
Posted on: 11/22/2019

Case Manager
Description: We are more than a health system. We are a belief system. We believe wellness and sickness are both part of a lifelong partnership, and that everyone could use an expert guide. We work hard, care deeply (more...)
Company: Ohio Health
Location: Columbus
Posted on: 11/22/2019

Project Manager
Description: Job DescriptionAs a Project Manager for our client, you will be responsible for overseeing projects ranging from 1M to 20M in size. The biggest responsibilities as the Project
Company: Michael Page
Location: Columbus
Posted on: 11/22/2019

Director, Planning and Fulfillment
Description: Company Profile: br A world leader in innovative, casual footwear, Crocs, Inc. is dedicated to the Future of Comfort. Our original and most famous style, the Classic Clog, is instantly recognized around (more...)
Company: Crocs, Inc.
Location: Dayton
Posted on: 11/22/2019

CCB - Home Lending - Control Manager - Vice President
Description: The company is a leading global financial services firm with operations worldwide.--Create--a proactive risk and control culture that leverages proven evaluation strategies and
Company: JPMorgan Chase & Co.
Location: Columbus
Posted on: 11/22/2019

District Manager
Description: We are seeking a District Manager to drive our centers to achieve new levels of greatness District Managers play an integral role in European Wax Center growth. They serve as inspiring leaders to their (more...)
Company: European Wax Center
Location: Columbus
Posted on: 11/22/2019

Log In or Create An Account

Get the latest Ohio jobs by following @recnetOH on Twitter!

Columbus RSS job feeds