Medical Director - Part-time

Socket.dev; Chicago (IL); On-site; USD 230,000 - 300,000; Full time

Job summary

Zing Health is seeking a Medical Director to provide medical oversight and guidance on clinical appropriateness and utilization for plan members. You will educate network providers and medical managers on utilization practices, guidelines, and regulatory requirements, driving quality and cost-efficient care.

You will lead clinical protocols, participate in committees, and mentor staff while leveraging data analytics to improve member outcomes and ensure compliance with CMS, NCQA, and other

Qualifications

• Proven data analysis and interpretation skills for quality and utilization management.
• Minimum 5 years leading teams and achieving structured goals.
• Minimum 10 years of established clinical experience and current clinical knowledge.
• 2+ years HMO/Managed Care experience preferred.
• Proven competency with Microsoft Office applications (Word, PowerPoint, Excel, Outlook).

Responsibilities

• Participates as member of Health Services management team to develop and implement clinical programs to improve member outcomes.
• Utilization Review
• Case Management Rounds
• Integrated Care Rounds
• Active Participation with training
• Maintain documentation compliant with Health Plan and CMS policies and procedures
• Meet or exceed all Plan Turnaround times for assigned tasks
• Perform other related duties and/or projects as assigned by the CMO

Skills

Data analysis

Leadership

Team management

Clinical governance

Education

Board Certified MD

Active and Unrestricted Medical License (US)

Tools

Microsoft Word

Microsoft PowerPoint

Microsoft Excel

Microsoft Outlook

Job description

COMPANY OVERVIEW

Zing Health is a tech-enabledinsurance company making Medicare Advantage the best it can be for those65-and-over. Zing Health has a community-based approach that recognizes theimportance of the social determinants of health in keeping individuals andcommunities healthy. Zing Health aims to return the physician and the member tothe center of the health care equation. Members receive individualized assistanceto make their transition to Zing Health as easy as possible. Zing Health offersmembers the ability to personalize their plans, access to facilities designedto help them better meet their healthcare needs and a dedicated care team. Formore information on Zing Health, visit www.myzinghealth.com.

SUMMARY DESCRIPTION:

Under the direction of theChief Medical Officer, the Medical Director provides medical oversight and expertise in the clinical appropriatenessand medical necessity of healthcare services provided to Plan members,targeting improvements in efficiency and satisfaction for patients andproviders, as well as meeting or exceeding productivity standards. Educates andinteracts with network and group providers and medical managers regardingutilization practices, guideline usage, pharmacy utilization and effectiveresource management. Facilitates conformance to Medicare, NCQA and otherregulatory requirements. Reviews referred quality of care issues, focusedreviews and recommends corrective actions where appropriate. Conductsretrospective reviews of claims and appeals and resolves grievances related tomedical quality of care. Attends or chairs committees as required such asCredentialing, P&T and others as directed by the Chief Medical Officer.

Evaluatesauthorization requests in support of nurse reviewers; reviews cases requiringconcurrent review and manages the denial process utilizing CMS clinicalpolicies, InterQual, Milliman or other identified Evidence based MedicalPolicies. Monitors service delivery to our members through the continuum fromoutpatient services, acute and sub-acute hospital care, skilled nursingfacilities to home care to ensure quality, cost-efficiency, and continuity ofcare. Ensures medical decisions are rendered by qualified medical personnel,not influenced by fiscal or administrative management considerations, and thatthe care provided meets the standards for acceptable medical care. Ensures thatmedical protocols and rules of conduct for plan medical personnel are followed.Monitors practitioner practice patterns and recommends corrective actions ifneeded.

As a member of the HealthServices Management team, the Medical Director is responsible for assisting inthe development, implementation and review of clinical protocols, performanceobjectives, productivity benchmarks. Also, the position serves ascoach/mentor/trainer to staff clinicians and other staff, giving guidance onbest practices, reviewing the delivery of medical services, and identifying operationalissues which may impact Member outcomes or staff performance. The MedicalDirector will assist in examining clinical reporting, predictive analytics, andguidelines to identify members for specific case management and/or diseasemanagement interventions by utilizing established screening criteria. They will conduct admission review, post-discharge,and discharge planning with the health plan clinical staff. The Medical Director will be a keyparticipant in integrated case management rounds and actively seek additionalresources or expertise as needed to assist the member to achieve their bestpersonal health care goals.

Ableto utilizes IT and data analysis tools to report on, monitor outcomes, and makesuggestions to improve Utilization Management processes and outcomes. Activelyparticipates in regulatory, professional and community activities.

Experiencedemonstrating strong management and communication skills, consensus buildingand collaborative ability, and financial acumen.

ESSENTIAL FUNCTIONS:

• Participates as member of theHealth Services management team to develop and implement clinical programs to improve member outcomes.
• Utilization Review
• Case Management Rounds
• Integrated Care Rounds
• Active Participation withtraining
• Maintain documentationcompliant with Health Plan and CMS policies and procedures
• Meet or exceed all Plan Turnaroundtimes for assigned tasks
• Perform other related dutiesand/or projects as assigned by the CMO

QUALIFICATIONSAND REQUIREMENTS:

JOB REQUIREMENTS:

Required Qualifications

Education/Experience:

• Board CertifiedMD with an active and unrestricted Medical license in the United States
• Minimum5 years of experience in leading teams and working with colleagues to identifyand achieve structured goals.
• Minimum 10years of established clinical experience and current clinical knowledge.
• 2+ years HMO/Managed Care experience preferred
• Possess data analysis andinterpretation skills with prior experience working with teams focusing onquality management, utilization management, discharge planning and/or casemanagement.
• Proven competency with MicrosoftOffice, Word, PowerPoint, Excel, Outlook

Preferred Qualifications

• Minimum5 years’ experience in the managed care industry including Medicare, MedicareAdvantage including experience in Utilization/QualityProgram management. HMO/Managed Care experience.
• Knowledgeof applicable state, federal and third-party regulations
• Experiencein Peer Review, medical policy/procedure development, provider contractingexperience.
• Experiencewith NCQA, HEDIS, Medicaid, Medicare and Pharmacy benefit management, Group/IPApractice, capitation, HMO regulations, managed healthcare systems, qualityimprovement, medical utilization management, risk management, risk adjustment,disease management, medical coding and evidence-based guidelines.