Medical Director

JOB PURPOSE:The Medical Director will lead the Medical areas of the company, which include: Precertification, Case Management and Medical Audit to ensure the development of a solid and scalable operational platform with the objectives of ensuring our members receive optimal medical care within policy guidelines and delivering superior service. The Medical Director must have outstanding communication and interpersonal skills, as well as the ability to manage multiple projects and implement high quality work processes.ESSENTIAL JOB DUTIES AND RESPONSIBILITIESEstablish the medical strategy the company and ensure it is consistently applied throughout the different medical areasLead the medical areas in defining and executing high quality and consistent work processes through internal training and continuous process improvementReview and approve high-cost services, such as air ambulance, transplant, chemotherapy/radiation, etc.Performs benefit-driven medical necessity reviews for coverage, case management, and claims resolution purposes using benefit plan information, clinical guidelines and clinical best practices.Ability to gain an in-depth understanding of the operation to effectively review and optimize internal processes that result in efficiency gains and cost reduction within the medical areasChampion and implement solid medical decision-making practices across the operation to enhance the level of serviceDefine key performance indicators and supervise department’s budget and staffingWork with the company’s Actuary on continuous evaluation and updating of standards/guidelines and best practicesEnsure medical guidelines are applied consistentlyDeliver outstanding service to internal and external customersDevelop staffing and resource models to balance workload and ensure teams are up to date with their assignmentsParticipate in the Policy Review process and propose changes based on medical perspectiveFoster working relationships with agents and communicate with them as appropriate via phone calls, email, seminars and conventionsCollaborate closely with all areas of the business, such as Client Services, Operations, Providers, Actuarial, Legal, Marketing and SalesDirect the Case Management process to ensure that all related activities meet predefined performance standards and procedural guidelinesOversee and direct cost control activities within medical areas to include: defining negotiation strategy, goals and expectations for physicians; monitoring savings; and establishing UCR guidelinesLead the team of medical audit; Establish the communication protocol to enhance collaboration between audit and other areas of the Precertification TeamActs as coach and motivator lending support and guidance to staff; ensures that medical staff is properly trained by providing internal and external training opportunitiesLead internal educational programs, such as medical terminology and CPT training, to enhance employee knowledge leading to improved service and productivity levelsOversee, define requirements and support the on-call processDefine and set approval levels required for the various types of casesDefine overtime criteria to include qualifications, staff selection and approval requirementsResearch, propose and approve tools to enhance productivity and accuracy of medical dataDESIRED MINIMUM QUALIFICATIONSStrong knowledge of medical conditions and their potential cost impactStrong knowledge of managed care policies and principlesAble to measure risk and potential downside to claims decisionsAble to lead cross-functional teamsExperience with change management principlesStrong analytical skills and detailed orientedAble to work independently. Excellent time management skills and ability to prioritizeExcellent public speaking/presentation skillsStrong commitment to service and qualityBilingual (must be fluent in English and Spanish) - speak, read and write, Portuguese a plusFamiliar with health insurance principles and guidelinesFamiliar with Milliman guidelinesExperience in participating and/or developing medical distinction programsEDUCATION AND EXPERIENCE10+ years of medical experience in hospitals and/or health insurance companies (preferably with international major medical products)5+ years of management experience or equivalent experience implementing projectsTrack record leading teams to deliver superior service in fast-paced entrepreneurial companyMedical Doctor degree (U.S. or foreign) #J-18808-Ljbffr