Example job description
Job Description
JOB TITLE:
|
Medical Director-Gov’t Programs/QM
|
DATE:
|
November 2007
|
DEPARTMENT:
|
Medical & Quality Management
|
JOB CODE:
|
250150
|
REPORTS TO:
|
Sr. Medical Director and/or
Sr. VP/Chief Medical Officer
|
FLSA STATUS:
|
Exempt
Nonexempt
|
PREPARED BY:
|
CMO
|
HR REVIEW:
|
|
POSITION PURPOSE:
To direct Medical Services activities related to Government Programs, including but not limited to: CMS, Federal Employees Program, and Medicaid. Oversee utilization and quality management activities including support of collaborative relationships with physicians and hospitals to achieve mutually acceptable business goals.
MINIMUM POSITION REQUIREMENTS:
Required Experience:
· Five years of clinical practice
· Two years health plan managed care (either with a medical group or health plan) utilization management, health care quality improvement (such as NCQA, CMS), and in the development and implementation of clinical practice guidelines
Required Education:
· Doctorate Degree in Medicine
Required Certifications/Licenses:
· Current, unrestricted medical license – either Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO)
Required Knowledge, Skills and Abilities (KSAs):
Knowledge of:
· Knowledge of Continuous Quality Improvement theory and practice
· Healthcare financing and the relation to various products (HMO, PPO, Indemnity, and Medicare Advantage) and the health care delivery system
Skills:
· Planning and decision-making skills.
· Leadership skills
· Basic computer skills (including Microsoft Word and Excel)
PREFERRED QUALIFICATIONS:
· Knowledge of data management and information systems
· Board certification by an ABMS recognized specialty board
· Experience with Disease Management, Quality Management, and Pharmacy Management
PRIMARY ACCOUNTABILITIES:
1. Direct medical management utilization activities, Disease Management and Quality Management programs as necessary to maintain compliance with government programs, including but not limited to CMS, FEP, Medicaid, and other accrediting bodies for which there is a business need.
2. Provide medical expertise and collaboration for all Disease Management, Quality, Pharmacy, Care Management, and Medical Review initiatives.
3. Support collaborative relationships with physicians and hospitals.
4. Evaluate and modify medical decision-making policies and review criteria as appropriate.
5. Participate in Medical Management strategic planning in evaluating utilization, quality, national and local trends, and identify interventions to optimize the utilization of resources and the delivery of high quality health care services.
6. Participate in the Appeals and Grievance process to assure timely, accurate responses to members and providers.
7. Provide written information to members and providers through letters, articles and editorials in various BCI publications.
8. Create strategic opportunities to control cost and increase quality.
9. Work to assure productive relationships with all customers, employers, members, and providers to assure that members receive appropriate health care in the most appropriate setting with the best value in health care.
10. Work collaboratively with Actuarial, Marketing, Provider Services, and Claims to assure optimal customer service while assuring contract defined resource management.
11. Work closely with other Medical Directors, Director of Medical Quality Management, Director of Pharmacy, Medical Directors of Physician Networks and all other departments and divisions
SECONDARY ACCOUNTABILITIES:
1. This position may serve as a member or chair the following committees:
§ Quality Management Committee
§ Credentialing Committee
§ Medical/Quality Management Leadership Committee
§ Pharmacy and Therapeutic Committee
§ Physician Advisory Panel
§ Other committees, public and internal, as assigned
2. Perform other duties as deemed necessary by the Sr. Medical Director and/or Sr.VP/Chief Medical Officer.
Job Description
JOB TITLE:
|
Medical Director-Gov’t Programs/QM
|
DATE:
|
November 2007
|
DEPARTMENT:
|
Medical & Quality Management
|
JOB CODE:
|
250150
|
REPORTS TO:
|
Sr. Medical Director and/or
Sr. VP/Chief Medical Officer
|
FLSA STATUS:
|
Exempt
Nonexempt
|
PREPARED BY:
|
CMO
|
HR REVIEW:
|
|
POSITION PURPOSE:
To direct Medical Services activities related to Government Programs, including but not limited to: CMS, Federal Employees Program, and Medicaid. Oversee utilization and quality management activities including support of collaborative relationships with physicians and hospitals to achieve mutually acceptable business goals.
MINIMUM POSITION REQUIREMENTS:
Required Experience:
· Five years of clinical practice
· Two years health plan managed care (either with a medical group or health plan) utilization management, health care quality improvement (such as NCQA, CMS), and in the development and implementation of clinical practice guidelines
Required Education:
· Doctorate Degree in Medicine
Required Certifications/Licenses:
· Current, unrestricted medical license – either Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO)
Required Knowledge, Skills and Abilities (KSAs):
Knowledge of:
· Knowledge of Continuous Quality Improvement theory and practice
· Healthcare financing and the relation to various products (HMO, PPO, Indemnity, and Medicare Advantage) and the health care delivery system
Skills:
· Planning and decision-making skills.
· Leadership skills
· Basic computer skills (including Microsoft Word and Excel)
PREFERRED QUALIFICATIONS:
· Knowledge of data management and information systems
· Board certification by an ABMS recognized specialty board
· Experience with Disease Management, Quality Management, and Pharmacy Management
PRIMARY ACCOUNTABILITIES:
1. Direct medical management utilization activities, Disease Management and Quality Management programs as necessary to maintain compliance with government programs, including but not limited to CMS, FEP, Medicaid, and other accrediting bodies for which there is a business need.
2. Provide medical expertise and collaboration for all Disease Management, Quality, Pharmacy, Care Management, and Medical Review initiatives.
3. Support collaborative relationships with physicians and hospitals.
4. Evaluate and modify medical decision-making policies and review criteria as appropriate.
5. Participate in Medical Management strategic planning in evaluating utilization, quality, national and local trends, and identify interventions to optimize the utilization of resources and the delivery of high quality health care services.
6. Participate in the Appeals and Grievance process to assure timely, accurate responses to members and providers.
7. Provide written information to members and providers through letters, articles and editorials in various BCI publications.
8. Create strategic opportunities to control cost and increase quality.
9. Work to assure productive relationships with all customers, employers, members, and providers to assure that members receive appropriate health care in the most appropriate setting with the best value in health care.
10. Work collaboratively with Actuarial, Marketing, Provider Services, and Claims to assure optimal customer service while assuring contract defined resource management.
11. Work closely with other Medical Directors, Director of Medical Quality Management, Director of Pharmacy, Medical Directors of Physician Networks and all other departments and divisions
SECONDARY ACCOUNTABILITIES:
1. This position may serve as a member or chair the following committees:
§ Quality Management Committee
§ Credentialing Committee
§ Medical/Quality Management Leadership Committee
§ Pharmacy and Therapeutic Committee
§ Physician Advisory Panel
§ Other committees, public and internal, as assigned
2. Perform other duties as deemed necessary by the Sr. Medical Director and/or Sr.VP/Chief Medical Officer.
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