Medical Director

Job Summary

Reporting to the Chief Medical Officer of Prominence Health Plan (PHP), the Medical Director will direct the development of goals and objectives and the activities related to their achievement for the Health Services Department of PHP which include Utilization Management, Care Management, Disease Management, Quality Improvement, Pharmacy Management, Risk Adjustment, and Community Provider Relations.

The Medical Director will provide leadership for the above-mentioned departments and may be asked to participate with and lead other multi-disciplinary or cross functional task-oriented groups within PHP and as appropriate other internal and external units.

Staff Medical Directors hold an active, unrestricted, valid, and current licenses to practice medicine in Nevada, Texas, and/or Florida and are board-certified by a specialty board approved by the American Board of Medical Specialties or the Advisory Board of Osteopathic Specialists or a Doctor of Podiatric Medicine. They are qualified to render appeal determinations in addition to initial determinations and non-certifications.

This individual will play a key role in the direction and execution of the PHP success in Nevada, Texas, Florida, and other markets as indicated related to the delivery of medical services in a population management environment.

This medical leader will be responsible for strategically developing and enhancing the existing Medical Management Service Department in the areas of medical policy and procedures, utilization management, peer-to-peer clinical review, pharmacy management, quality of care, quality of service, physician enhancement and development, case/disease management, and appropriate documentation and coding.

Furthermore, this medical leader will, as necessary, provide the skills and experience necessary in working with the marketing and sales department to assist in new membership growth and as necessary key account retention.

The Medical Director will be expected to work closely with Provider Relations, represent the organization at key community clinical functions, be visible at important regional and national meetings, and visit medical/hospital entities on a regular basis.

Qualifications and Requirements

• Doctorate Degree in Medicine; in addition to a Master's in health care administration or related field (MBA, MMM, MPH or MHA) preferred.
• Board-certified by a specialty board approved by the American Board of Medical Specialties or the Advisory Board of Osteopathic Specialists or a Doctor of Podiatric Medicine is preferred.
• Possess a current, valid, active, and unrestricted license or certification in a health profession to practice medicine in a state or territory of the United States.
• Free of sanctions from MD Medicaid or Medicare.
• Previous Associate Medical Director/Medical Director experience preferred.
• Minimum five years clinical practice and post-graduate experience in direct patient care.
• Familiarity with Managed Care Principles.
• Familiarity with HEDIS/CAHPS/STARS/HOS/NCQA/URAC.

Skills

• Excellent computer skills.
• Strong internal relationship building skills required.
• Strong external relationship skills required with contracted providers.
• Excellent presentation, oral and written communication skills required.
• Able to travel to all PHP markets and represent the Plan.