Medical Director

JOB DESCRIPTION

Work within and outside Medical Management to provide support and address matters that require physician input on items such as the ones listed below (as needed).

Reviews

Perform pre, post, and concurrent utilization review determinations. *Note: This would be a shared responsibility with our current part-time Medical Director.

Committees/Process Support

Serve on Grievance and Appeals Committee (provider or member) as Medical Advisor which includes OCI complaints and IRO reviews.
Member of the following committees:
Medical Policy Committee
Credentialing Committee
CPPC committee
Quality Improvement Committees for health plans and other committees as assigned.
Support policy development using evidence-based criteria.
Work with Medical Coder to review new CPT and HCPS code as they are released quarterly.
Produce a “Doctors Note” quarterly that will be included in the provider newsletter.
Representative based on accreditation requirements.
Participate in Certificate reviews and support.
Participate in group RFP/renewal presentations as needed.

Staff Support

Serve as Clinical Advisor for Integrated Care Management.
Perform peer-to-peer requirements for discussing cases with contracted providers.
Provide support to the nursing staff which includes assisting in staff training to ensure consistency in applying policy criteria and educate regarding new procedures, including services and changes in certificate language.
General support functions as needed for the Medical Management department.