Chief Medical Director

Job Description

Position Purpose: Direct and coordinate the medical management, quality improvement and credentialing functions for the assigned business unit based on, and in support of the strategic plan, establishing the strategic vision and attendant policies and procedures.

Serves as clinical advisor to and educator of medical management staff making sure correct clinical judgment is applied to all medical management determinations.

Oversees internal medical review guidelines to ensure clinical integrity and compliance and acts as a resource for staff members throughout the operation.

Coordinates with other departments, the responses needed to address regulatory accreditation concerns pertaining to medical management issues

Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services.

Facilitates the achievement of the Medical Management Program goals through an effective health services delivery system.

Responsible for physician review and oversight of all potential adverse determinations including pre-certifications/prior authorizations, concurrent review and appeals/retrospective review.

Responsible for HEDIS improvement and strategy.

Actively participates in the auditing process of medical management processes and corrective action team projects for medical management

Achieves utilization, cost management and quality goals.

Participates and advises in the development of corporate medical policies for UM, pharmacy, and new technology.