Associate Medical Director

$500 SIGN ON BONUS for Washington, DC residents

*Parking and Metro stipend offered*

Conveniently located on the Red Line at Van Ness-UDC Station

Job Summary

Minimum Qualifications

Education/Training:

Medical Degree from an approved School of Medicine or Osteopathy

Experience:

Minimum of 5 years experience in clinical practice. A minimum of 2 years previous experience in a managed care environment is preferred. Prior experience with NCQA certification, HEDIS reporting and working with Departments of Health or other government agencies, government sponsored programs and recipients preferred.

License/Cert/Reg:

Active Medical Licenses in Maryland and the District of Columbia without restriction including no current, prior or pending Medicare or Medicaid Sanctions are required. Active Board Certification in a medical specialty as recognized by the American Board of Medical Specialty (ABMS) is required.

Knowledge, Skills & Abilities:

Ability to read, comprehend, and write English language. Demonstrated skills in clinical judgment. Working knowledge of managed care utilization management approaches and principles. Demonstrated ability to communicate and educate practitioners regarding principles of utilization management and quality assurance. Ability to communicate clearly in a verbal and written manner. Strong interpersonal skills. Competent in conflict management, negotiating, problem solving, time management, and human relations. Demonstrated ability to be organized and efficient in prioritizing and managing assignments within minimal oversight and direction. Analytical skills necessary to assess utilization data and formulate useful reports. Basic computer skills required.

Primary Duties and Responsibilities

1. Standard Job Duty: Develops department goals, objectives, policies, and procedures. Ensures compliance with business unit policies and procedures and governmental and accreditation regulations including Maryland COMAR, the District of Columbia, External Quality Review Organization (EQRO) Systems Performance Review Standards, Annual Evaluation of Drug Use Management Programs, and the National Committee for Quality Assurance (NCQA) for Health Plans and HEDIS Technical Specifications according to plan needs.
2. Standard Job Duty: Develops and recommends department operating budget and manages resources according to approved budget. Contributes to strategic planning regarding medical spend and programs.
3. Standard Job Duty: Selects, trains, orients, and assigns department staff. Develops standards of performance, evaluates performance, and conducts performance management planning. Initiates or makes recommendations for personnel actions. Maintains ongoing communication with subordinates to review programs, provide feedback, discuss new developments, and exchange information.
4. Executes individual assigned tasks and ensures overall operational adherence that complies with governmental and accreditation regulations including Maryland COMAR, District of Columbia Contract, External Quality Review Organization (EQRO) Systems Performance Review Standards, Annual Evaluation of Drug Use Management Programs, and the National Committee for Quality Assurance (NCQA) for Health Plans and HEDIS Technical Specifications according to plan needs.
5. Performs review of current inpatients, precertification requests, pharmacy requests, review of emergency department visits, review of appeals, and consultations with nurse case managers and other associates. Performs all types of utilization review tasks for members of MedStar Family Choice (MFC) according to Utilization Management (UM) criteria and based on medical necessity. Makes all UM decisions based only on appropriateness of care and service and the existence of coverage. Neither incentives nor disincentives will be paid in conjunction with UM decisions.

6. Works collaboratively with all areas of MFC where the clinical expertise of physicians is needed to support operations of the health plan.

7. Prepares written responses in accordance with policies and procedures within standards set forth by the State of Maryland, the District of Columbia Contract, the EQRO and/or NCQA and documents in the MFC clinical software system. Adheres to deadlines to ensure timeliness of decisions in accordance with policy.

8. Establishes and maintains a high level of communication and collaboration with staff in Utilization Review/Case Management and Denial & Appeals Department, Outreach and Provider Relations.
9. Educates practitioners about utilization practices to promote high quality, cost effective care. Interacts with practitioners regarding issues related to utilization via Peer to Peer Process, telephone, written word and email.
10. Supports the activities of Provider Relations in its role to educate and maintain an adequate, high quality network of providers and practitioners, as assigned.

11. Supports the activities of the Quality Department in the areas of HEDIS, EPSDT and other quality initiatives to achieve MFC Quality Goals.
12. Establishes and maintains a high level of communication with clinical staff in Utilization Review/Case Management and Denial & Appeals Department and supports achievement of department goals.

13. Contributes to the development, implementation monitoring, documentation and analysis of clinical care and quality improvement programs as requested.

14. Participates in inter-rater reliability process.
15. Participates in the development and review of utilization review standards for inpatient, outpatient, surgical and special procedure utilization on a prospective, concurrent and retrospective basis and medical policy as assigned
16. Contributes to the achievement of established MFC goals and objectives and adheres to department policies, procedures, quality standards, and safety standards
17. Supports the mission, vision and values of MedStar Health and contributes to the achievement of the goals of MedStar Health

18. Standard Job Duty: Participates in meetings and on committees and represents the department and business unit in community outreach efforts.
19. Standard Job Duty: Participates in multidisciplinary quality and service improvement teams and maintains effective working relationships with other departments.
20. Standard Job Duty: Performs other duties as assigned.