Associate Medical Director

In support of the CMO, the Associate Medical Director is responsible for the administration of procedures, protocols, and standards regarding the efficiency and quality of the health care delivered to Network Health (NH) members. This individual will be chair of at least 3 committees related to quality and accreditation.Location: Candidates must reside in the state of Wisconsin for consideration. This position is eligible to work at your home office (reliable internet is required). Travel is required occasionally for the position.Hours: 1.0 FTE, 40 hours per week, 8am - 5pm Monday through Friday, weekend coverage required on rotational basisCheck out our 2025 Community Report to learn a little more about the difference our employees make in the communities we live and work in. As an employee, you will have the opportunity to work hard and have fun while getting paid to volunteer in your local neighborhood. You too, can be part of the team and making a difference. Apply to this position to learn more about our team.Job Responsibilities:Assist the CMO with monitoring availability, appropriateness, and necessity of care rendered by participating providers and by out-of-plan providersParticipate in oversight and clinical decision making of the UM program, including but not limited to rendering denial determinations for services not considered medically necessary or experimental/investigation/unproven in accordance with regulatory and quality standardsContribute to the development of quality care guidelines, internal peer review procedures, and the evaluation of medical care evaluation studies under the NHP quality assurance programs. In coordination with the CMO and Directors of Health Management and QI and Disease Management, share responsibility for the development and continued evaluation of utilization review and quality assessment processesProvide medical consultation as requested for:Medical/legal issuesMember grievance proceduresDevelopment and implementation of new benefit packages and the interpretation of covered benefits in NHP contractsMedical issues related to contract negotiations with health care providersDetermining if services to members/enrollees meet medical criteriaPromote positive relationship between NHP and medical communityServe as liaison between NHP and providers regarding matters of medical policy and medical administrationServe as spokesperson for NHP in the medical community and maintains appropriate contact with professional health care organizationsParticipates in the ongoing recruitment of plan physicians.Respond to physicians and other provider inquiries and complaints within established guidelines of the Executive Committee and Board of DirectorsAssist in the development of appropriate medical guidelines and parameters for claims reviewAssist in the training of NHP staff on matters relating to medical guidelinesOversight responsibility for monitoring and evaluating Medicare Special Needs Plan Model of Care effectivenessPerform second level review of provider appeals and disputesServe on committees as coordinated with the CMOAssist in strategic planning targeted towards plan growth initiativesJob Requirements:Doctor of Medicine (MD or DO), licensed in the state of Wisconsin without restrictionMember in good standing of the local medical community. An active practitioner of medicine in the NHP service areasMust possess a thorough knowledge of the health professional and facilities and standards of practice of medicine in NHP’s service areaMust possess sufficient medical experience and other experience, including knowledge of the Medicare program, to review organization determinations involving medical necessityBoard certified in an ABMS medical specialty requiredNetwork Health is an Equal Opportunity EmployerJob SummaryRequisition Number: ASSOC002310Job Category: Health ManagementSchedule: Full-Time