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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 www.wellcare.com. 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

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