Responsible for the administration of physical and/or behavioral health medical services, to ensure the appropriate and most cost-effective medical care is received.
Location: This position will work a hybrid model (remote and office) and must live within 50 miles of one of our Pulse Point office locations. (Louisiana is preferred)
Hours: Part time position at least 20 hours a week (works on weekends and some holidays.)
How will you make an impact:
May be responsible for developing and implementing programs to improve quality, cost, and outcomes. May provide clinical consultation and serve as clinical/strategic advisor to enhance clinical operations.
May identify cost of care opportunities.
May serve as a resource to staff including Medical Director Associates.
May be responsible for an entire clinical program.
Supports clinicians to ensure timely and consistent responses to members and providers.
Provides guidance for clinical operational aspects of a program.
Conducts peer-to-peer clinical reviews with attending physicians or other providers to discuss review determinations, and patients' office visits with providers and external physicians.
May conduct peer-to-peer clinical appeal case reviews with attending physicians or other ordering providers to discuss review determinations.
Serves as a resource and consultant to other areas of the company.
May be required to represent the company to external entities and/or serve on internal and/or external committees.
May chair company committees. Interprets medical policies and clinical guidelines.
May develop and propose new medical policies based on changes in healthcare.
Leads, develops, directs, and implements clinical and non-clinical activities that impact health care quality cost and outcomes.
Identifies and develops opportunities for innovation to increase effectiveness and quality.
Minimum requirements:
Requires MD or DO and Board certification approved by one of the following certifying boards is required, where applicable to duties being performed, American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA).
Must possess an active unrestricted medical license to practice medicine or a health profession.
Unless expressly allowed by state or federal law, or regulation, must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US military base, vessel or any embassy located in or outside of the US.
Minimum of 10 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
For Health Solutions and Carelon organizations (including behavioral health) only, minimum of 5 years of experience providing health care is required. Additional experience may be required by State contracts or regulations if the Medical Director is filing a role required by a State agency.
For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
If this job is assigned to any Government Business Division entity, the applicant and incumbent fall under a sensitive position' work designation and may be subject to additional requirements beyond those associates outside Government Business Divisions.
Requirements include but are not limited to more stringent and frequent background checks and/or government clearances, segregation of duties, principles, role specific training, monitoring of daily job functions, and sensitive data handling instructions.
Associates in these jobs must follow the specific policies, procedures, guidelines, etc. as stated by the Government Business Division in which they are employed.
Preferred Skills, Capabilities, and Experiences:
Strong preference for candidates with experience in pediatrics.
Must hold an active, unrestricted medical license or health profession certification to practice in the state of Louisiana. Candidates without current licensure in Louisiana must be willing to obtain it.
