GENERAL PURPOSE: Provide clinical and quality improvement leadership pertaining to the application of medical practice processes and incorporate changes in the current health care continuum that focuses on all health care providers. Support the development and implementation of all corporate projects and consequent analyses for appropriate reporting formats to clients. Assist in the development of new business, presentations and publications.
DUTIES AND RESPONSIBILITIES: Provides clinical support for beneficiary protection, medical utilization, and quality of care reviews.
Participates in the review of complex, controversial and/or unique cases as required. Solicits and evaluates advice of external medical and allied health consultants with respect to said reviews as needed.
Recruits and leads a team of physician reviewers
Establishes and maintains effective communication with executive leadership and with external collaborators, partners, and stakeholders.
Facilitates the recruitment of clinical consultants; reviews and approves all credentialing and re-credentialing applications of clinical consultants; makes recommendations to the Clinical Quality Management Council for de-credentialing of clinical consultants, as needed.
Ensures the organization has qualified clinicians accountable to the organization for decisions affecting consumers.
Maintains current literature knowledge regarding health care quality improvement, health care reform and changes affecting health care systems (inpatient, ambulatory care, managed care), federal and state-based regulations, and CMS policy/procedures.
Represents company as a speaker and physician liaison at medical society, provider and hospital medical staff meetings.
Adheres to all relevant compliance regulations (HIPAA, URAC, FISMA, CMS).
Requirements: MD or DO degree with current licensure in the State of Michigan. Additional Quality Improvement training preferred.
Current board certification in a medical specialty recognized by the American Board of Medical Specialties.
Previous experience as a Medical Director within a payer or hospital
Experience with InterQual Physician Documentation
Knowledgeable in current evidence-based practice guidelines.
Knowledgeable in Continuous Quality Improvement methods.
Conceptual understanding of statistical analysis and ability to communicate concepts clearly both verbally and in writing.