Offer summary

Qualifications:

Board certified physician with post-graduate experience in direct patient care required., Experience in Health Plan utilization management and knowledge of process improvement tools., Active and unrestricted license to practice medicine in Maine or New Hampshire, or eligibility for licensure in another U.S. state., Strong analytical skills and excellent interpersonal abilities to build relationships with providers and internal staff..

Key responsabilities:

Provide clinical leadership and direction to the utilization and care management functions of the health plans.

Perform medical necessity reviews and contribute to case reviews for quality and safety of care.

Assist in the development of Utilization Management and Care Management Program Descriptions to meet accreditation standards.

Work collaboratively with various departments to manage health plan medical costs and improve performance metrics.

Job description

Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.

Position Summary

The Medical Director (MD) provides clinical leadership and direction to the utilization & care management functions of Martin’s Point’s Health Plans. The MD works collaboratively with other plan functions that interface with Medical Management such as Health Management, Compliance and Appeals, , Network Management, Member Services, benefits & claims management, and Compliance. In this role, there is the opportunity to assist in or drive short and long-range clinical programming, quality management, and external relationships. The Medical Director reports to the Vice President Health Plan Medical Director and works closely with the other Health Plan leaders.

Job Description

Key Outcomes:

Responsible and accountable to the Health Plan Medical Director for helping to manage health plan medical costs by assuring clinically appropriate health care delivery for health plan products and services utilizing Evidence-Based Guidelines to ensure the right service at the right time and place for each member
Performs medical necessity reviews of requests for health plan-covered services (benefits). Reviews disputes and appeals of said services for clinical appropriateness and in compliance with government program rules
Contributes to case reviews to ensure the quality and safety of care and services delivered to Martin’s Point Health Plan members.
Assists in the construction of the annual Utilization Management, Care Management, and Disease Management Program Descriptions and works to ensure the programs meet accreditation and regulatory standards (e.g. NCQA, CMS, TRICARE)
Participates in medical policy review and policy development.
Works with Informatics, Network Management, and Medical Economics to create and maintain a system where Network providers are properly assessed in regard to cost management and develops a plan and schedule for communication and solutioning with outliers.
Develops an in-depth understanding of ACOs and contributes to their management and strategic deployment.
Provides support to Health Plan risk adjustment activities as needed.
Is conversant with Health Plan key performance metrics, in particular utilization and cost management goals, MLR , inpatient days/1000, SNF days/1000, and clinical quality improvement (QI) objectives, including HEDIS and how to drive improvement in these areas

Education/Experience:

Board certified physician with post-graduate experience in direct patient care required
Medical leadership in, or focused activity of, a Health Plan (preferred)
Knowledge of process improvement tools
Experience in Health Plan utilization management
Experience in Medicare Advantage and/or TriCare preferred

Required License(s) and/or Certification(s):

Active and unrestricted license to practice medicine in Maine or New Hampshire; or another U.S. state with eligibility to apply for and obtain additional state licensure.
Current, or ability to have some, active clinical work with patients

Skills/Knowledge/Competencies (Behaviors):

Deep knowledge and practical understanding of Health Care systems and Managed Care concepts
Knowledge and deep commitment to performance-based Health Plan systems
Good analytic skills with the ability to identify meaningful trends and targets for improvement
Excellent interpersonal skills and demonstrated ability to establish rapport and working relationships with providers, service vendors and internal staff
Willingness to explore innovative methods of providing medical management
Supports the culture and models the MPHC values

We are an equal opportunity/affirmative action employer.

Do you have a question about careers at Martin’s Point Health Care? Contact us at: jobinquiries@martinspoint.org

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