Senior Medical Director, Quality & Utilization

Remote Jobs; United States; À distance; USD 180 000 - 240 000; Plein temps

Résumé du poste

Network Health seeks an Associate Medical Director to oversee procedures, protocols, and standards ensuring efficient, high-quality care for NH members. The role chairs at least three quality/accreditation committees and provides medical consultation on legal issues, grievances, and benefits interpretation.

The candidate must be a Wisconsin-licensed MD/DO, board-certified, and an active member of the local medical community with knowledge of Medicare/quality standards.

Qualifications

• Must possess MD or DO license in Wisconsin
• Board certification in an ABMS medical specialty required
• Active practitioner in NHP service areas preferred

Responsabilités

• Assist the CMO with monitoring availability, appropriateness, and necessity of care rendered by participating providers and by out-of-plan providers
• Participate in oversight and clinical decision making of the UM program, including denial determinations for services not considered medically necessary
• Contribute to the development of quality care guidelines and evaluate medical care studies under quality assurance programs
• Provide medical consultation for medical/legal issues, patient grievances, and interpretation of covered benefits
• Determine if services meet medical criteria
• Promote positive relationships between NHP and medical community
• Serve as liaison regarding medical policy and administration
• Participate in recruitment of plan physicians
• Assist in strategic planning for plan growth initiatives

Formation

MD or DO

Board certified in ABMS medical specialty

Description du poste

Network Health seeks an Associate Medical Director to oversee procedures, protocols, and standards ensuring efficient, high-quality care for NH members. The role chairs at least three quality/accreditation committees and provides medical consultation on legal issues, grievances, and benefits interpretation.

The candidate must be a Wisconsin-licensed MD/DO, board-certified, and an active member of the local medical community with knowledge of Medicare/quality standards.