Associate Medical Director - Managed Care, Utilization Management

Job Description We’re searching for an Associate Medical Director, someone who’s ready to be part of the best ranked children’s hospital in Texas, and among the best in the nation. In this position, you will be responsible for establishing health plans and medical policies. The Associate Medical Director provides guidance to areas within departments of the Texas Children's Health Plan (TCHP); oversees assigned functions of the health plan; provides support, education, and consultation to Texas Children's System staff and physicians, regarding resource utilization, managed care and continuity of care issues. Job Duties & Responsibilities Working with the CMOs and Medical Directors, you will oversee and provide recommendations to continuously improve the implementation of medical management programs as outlined in the policy and procedures. The programs include discharge planning; case and referral management; and the use of clinical protocols and medical review criteria. Working with the CMOs provides input into the development of standards for behavioral health care, practice guidelines, and medication management. Oversees the clinical professional review of behavioral health care by the registered nurses employed by the Health Plan and ensures regulatory compliance. Working with the CMOs and Medical Director for Utilization Management, provides input into the development of medical care guidelines for utilization of behavioral health services. Completes medical necessity reviews and appeals of requests for medical care based upon evidence‑based guidelines approved by the CAAC, using appropriate independent clinical judgment and not adversely influenced by fiscal management decisions. Documents denials of services not meeting medical necessity. Ensures that the UM Program reflects current philosophies in managed care and the stated values and goals of Texas Children’s. Working with the CMOs, develops guidelines and ensures office sites and medical records meet the standards for proper behavioral health care. Educates providers, as necessary. Supervises the use of physician profiles and educates the providers in the interpretation of these profiles. Using data obtained through encounter and claims information, and electronic medical records from the group practices and hospital, monitors outcomes of members. This function is also done in conjunction with the CMOs, Medical Affairs Office and the Quality and Outcomes Management Department. Identifies strategies to affect outcomes. Regulatory compliance and compliance with accreditation agencies – such as NCQA and TDI. Works with personnel in exceeding requirement of federal, state and accreditation agencies, and prepares for inspection and reviews by the above agencies. Participate in other Committees as directed by the CMO’s affecting patient care and medical policy, teaching programs and consults on managed care as necessary. Interacts with and participates in committees and medical functions of outside agencies to include primary HMOs, state and federal agencies, and professional organizations as directed by the CMOs. Quality Management: Participates in the QM Program of the Health Plan, and the Quality Improvement Committee (QIC), the staff committee entrusted with all aspects of QM for the Health Plan. Collaborates with CMOs on establishing QI standards and assures their implementation and use. Ensures that approved medical protocols, rules of conduct and compliance with standards of public health is followed by Plan medical staff and providers. Monitor health status and outcomes of members. Serves as a crucial member of the Health Plan operating team. Provides timely and accurate oral and written progress reports at staff meetings and to the CMO’s. Demonstrates excellent communication and conflict resolution skills. Skills & Requirements Required Doctor of Medicine (M.D.) or Doctorate Doctor of Osteopathic Medicine (D.O.) Required Licenses/Certifications MDL – Medical Doctor License by the Texas Medical Board and BCPP – BC Physician in Psychiatry by the American Board of Psychiatry & Neurology or BCP – Cert‑Board Certified Pediatrician by the American Board of Pediatrics or BCFM – Cert‑Board Certified Family Medicine by the American Board of Family Medicine or BCOBGYN – Cert‑Board Certified OB‑GYN by the American Board of Medical Obstetrics and Gynecology Required 5 years Healthcare management, managed care experience, and/or behavioral health experience Residency in Psychiatry and Child Psychiatry training, when primary role of the Associate Medical Director is Behavioral Health Candidates board certified in Pediatrics, Family Medicine or Emergency Medicine are highly preferred About Us Founded in 1996, Texas Children’s Health Plan is the nation's first health maintenance organization (HMO) created just for children. We provide STAR/Medicaid and Children's Health Insurance Program (CHIP) to pregnant women, teens, children and adults in Houston and surrounding areas. Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area. To join our community of 15,000+ dedicated team members, visit texaschildrenspeople.org for career opportunities. Texas Children’s is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children’s without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved. #J-18808-Ljbffr