MEDICAL DIRECTOR- HEALTHCARE COST MANAGEMENT- PHP
Location: Albuquerque New Mexico
Description: Presbyterian Healthcare Services is currently interviewing MEDICAL DIRECTOR- HEALTHCARE COST MANAGEMENT- PHP right now, this vacancy will be placed in New Mexico. Further informations about this vacancy opportunity please read the description below. Minimum Skills/Requirements
M.D. or D.O. degree, with board certification at some time. Five years clinical! practice experience. At least three years experience in a managed care setting. Experience crafting, implementing, monitoring, and championing clinical practice guidelines and resource, utilization, and cost management initiatives. Coursework or formal training in business desirable (e.g. M.B.A. or M.P.H. degree, courses sponsored by ACPE, Presbyterian Executive Leadership Program at RO Anderson School). Requires detailed knowledge of utilization management principles, including case management, retrospective and concurrent review, and prior authorization, in terms of theories and practices to serve as the resource or educator to other practitioners. Sound understanding of managed care environment, including various financing mechanisms (e.g., capitation). Familiarity with National Committee for Quality Assurance (NCQA) and with Health Plan Employer Data and Information Set (HEDIS) principles and requirements.
Primary Job Functions
- Assures missio! n, goals, and strategy of PHP/PHS are met via strategic planni! ng, operational management, and financial accountability in areas of responsibility
- Responsible, along with VP of Medical Affairs, for the Presbyterian Health Plan (PHP) Healthcare Cost Management (HCCM) Program. Primary responsibility for and direction of PHP healthcare cost management activities including direction and support for Health Services functions: nurses in prior authorization, concurrent and retrospective review, referral coordination, and case management activities.
- Serves as a healthcare cost management resource to all administrative staff of PHP, all PHP product line directors, PHP Health Services, participating providers, and the Presbyterian Medical Group. Provide leadership in the education of members, providers, and PHS entities in the principles of healthcare cost management, particularly as this relates to PHP. Serves as a resource to all customers in regards to national managed care trends, including new methods of management of popu! lations, healthcare costs, and of benefit design.
- Assists in the development of strategic plans for addressing HCCM concerns and opportunities. Responsible for recording/communicating progress toward meeting any outlined strategic objectives and/or goals.
- Ensures continuous familiarity with PHP primary care, specialist, inpatient, alternative care, and ancillary provider utilization patterns and costs. Assists in identifying and addressing utilization problems, and guiding staff to effective resolution through use of the CQI process.
- Liaison with external customers relative to HCCM programs and performance. Includes serving as a resource to internal personnel and creating and presenting information on HCCM to employers, brokers, governmental purchasers, and consumer advisory boards.
- Participates in ongoing identification, design, and development of clinical practice guidelines/disease management programs, prevention and wellness initiativ! es, clinical Quality Improvement Activities (QIA’s) incorporating bot! h national standards and local physician input. Serves on PMG UR/QA Committee to assist in development of clinical practice guidelines.
- Chairs and provides clinical leadership to the PHP Clinical Quality Committee.
- Participates in development and implementation of an outcomes-oriented PHP Quality Management Program.
- Provides initial Medical Director review of all quality of care complaints and participates in any process improvement initiatives that involve this function.
- Serves as the primary Medical Director resource to Pharmacy department personnel in the design, implementation, and continuous improvement of PHP’s pharmacy management program, including formulary development and maintenance
- Serves on the PHP Pharmacy and Therapeutics Committee and participates as an advisor in all pre-meeting planning with department staff.
- Serves as the Chairperson of the Medical Policy Committee to develop and approve Plan policies! and implementation plans regarding benefit development and interpretation. This includes responsibility for the maintenance of the Benefit Interpretation Manual.
- Participates in all strategic planning that relates to benefit and product design in the Medicare + Choice and Commercial/ASO areas.
- Works jointly with the Chief Medical Officer to review all Medical Directors’ roles and functions to ensure optimization of each of their roles and clear linkage of all their efforts to the strategic objectives and goals of the PHP Health Services department and of PHP.
- Directs or assists with process improvement initiatives as needed within each of their areas of work function/responsibilities.
- Coordinates process definition for the medical management grievance and appeals process, and serves as the coordinator for those components of the process requiring medical input and participation such as the external Level II appeal process.
- Rep! resents PHP as the Senior Medical Director in all Commercial Level III ! appeals at the DOI.
- Acts as liaison to external health organizations/committees
- Helps to ensure the implementation of an effective information system which is relevant in measuring both quality and utilization outcomes.
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If you were eligible to this vacancy, please email us your resume, with salary requirements and a resume to Presbyterian Healthcare Services.
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This vacancy starts available on: Fri, 03 May 2013 00:49:31 GMT
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