Job Description :
This job plays a crucial role in the corporation's success and works closely with all divisions and departments within the corporate structure to provide clinical consultation and support with regard to program development, compliance with accepted medical standards, and practitioner/provider education. The incumbent is an integral part of the utilization management team and assists utilization management staff by direct supervision or as otherwise appropriate to ensure delivery of quality and cost-effective care, member/provider satisfaction, and quality outcomes. A key component of this role is to review denials of care based on medical necessity. The incumbent acts as a liaison for Highmark Wholecare with practitioners/providers through ongoing communications and monitoring of services utilized. As such, the incumbent's role is to provide clinical input into health care management services' activities including for example, care and case management initiatives, clinical program development, and network management. These activities are by nature both line and staff functions. The incumbent assists operations/programs to comply with accreditation and regulatory standards, including but not limited to NCQA, Pennsylvania Department of Health regulations, Delaware Department of Health regulations, Department of Public Welfare, CMS, Highmark Wholecare corporate and medical policies.
Review utilization management cases and communicate the decisions to the member and provider.
Collaborate with Highmark Wholecare staff and physician advisory committees for development of Highmark Wholecare policies, procedures and special projects.
Active participation in establishing Highmark Wholecare's medical policy, and support established policy as it relates to the care management process and communications with practitioners.
Become familiar with the principles of continuous quality improvement and apply them in clinical and management functioning.
Establish priorities, manage projects in a timely manner, assume responsibilities with limited supervision.
Work as a team member coordinating the needs of multiple practitioners and providers across the network.
Attend meetings as appropriate, including medical director meetings, QI committee and subcommittees, as assigned.
Contribute to the education of other employees by direct consultation and formal presentation in topics of general interest.
Serve as a resource for information and consultation on the issues related to utilization management, clinical services and medical affairs, including such issues as case management, disease state management programs and health risk assessments.
Assist in the design/implementation of advanced care and case management strategies throughout the network of providers and practitioners to insure efficient care delivery of medical services.
Provide consultation to the care and case management staff, offer advice and assistance in achieving resolution of problem cases, and actively support care and case management activities.
Intervene as the spokesperson with local practitioners/providers to resolve care and case management issues and participate in the development of long-term strategies to create cost-effective medical care.
Assist in the design and development of medical management reports that can be used to identify opportunities for improvement in specific clinical areas.
Analyze utilization data and various forms of health care data available within and external to the corporation to evaluate effectiveness of clinical initiatives and care and case management processes.
Develop and implement corrective actions.
Conduct meetings, seminars, and conferences, and facilitate other forms of group interaction among physicians, in conjunction with other Highmark Wholecare executives and local administration, in order to promote sharing of information expertise, to foster program support, and to enhance identity with Highmark Wholecare.
Establish or maintain communication with practitioners and providers and become knowledgeable about their practice patterns in order to identify those factors of quality that define the best practices and once defined, helping them with continuous quality improvement.
Meet regularly with physicians and physician groups to represent the corporation in all matters as requested.
Become familiar with network issues and how to act as consultant to physicians at hospitals and health care management.
Identify specific factors for practices that fall below the standards of quality but have been achieved by the best practices and assist in modification of attitudes and behaviors to assist them in becoming best practices in the care of the patients.
Monitor clinical resource allocation, utilization and referral patterns, patient satisfaction, and clinical outcomes across the practitioner and provider network.
Develop understanding of current hospital and physician payment methodologies, and how they impact utilization incentives in the provider community.
Assist in the design and implementation of education programs for physicians and staff, establish education objectives, and identify resources to deliver educational services.
Evaluate physician feedback with regard to capitation, payment performance rewards, pay for performance methodology development and modification, etc. as appropriate.
Assist in various corporate initiatives to expand the network, retain practitioners and providers, and complete similar business initiatives.
Participate in network promotional activities with members and providers.
Seek to become knowledgeable about the regions' physicians, hospitals, and health care environment, and establish working relationships.
Establish effective working relationships with hospital, physicians and managers in order to bring about desired outcomes by affecting modifications in the practice patterns for both inpatient and outpatient services.
Support clinical program development initiatives through selection of program topics, establishment of criteria, and assisting with vendor selection based on the vendor's proposed approach to clinical management.
Monitor the clinical program initiatives in achieving desired quality and financial objectives.
Advise the Senior leadership of findings and lead development of corrective action plans as indicated.
Attend corporate QI committee meetings and selected subcommittee meetings and report on clinical initiatives and network management activities.
Serve as chairperson of the Physician Advisory and Quality Improvement Committees as appropriate, to provide oversight and direction to the quality improvement activities of the corporation.
Develop a working knowledge of the credentialing process and criteria and participate in education and sanctioning activities directed at individual network physicians.
Work with the credential staff to review provider applicants and to make decisions regarding approval, denial, and/or terminations according to Highmark Wholecare's policies and NCQA standards.
Become familiar with corporate credentialing policy, and assist in its design.
Become familiar with the principles of the TQM/CQI processes.
Seek to teach them and apply them in network medical functioning.
Regionally supervise and/or collaborate the activities/directives of the QI operations staff and committees.
Attend corporate QI committee meetings, and report on regional actions related to committee function.
Closely collaborate with the regional quality staffs to ensure maximum effectiveness within the organization.
Organizational providers - Assist in the evaluation and credentialing of organizational providers, including hospitals, home health agencies, SNFs, etc. Work closely with them to assure ongoing relationships with the corporation maximize their effectiveness.
Grievances and Appeals - Assist in the evaluation and resolution of grievances and appeals of patients, providers, and hospitals.
Maintain familiarity with applicable State and Federal Quality Assurance Regulations to ensure the organization's compliance with them.
Develop expertise in the external requirements for quality leadership, including NCQA accreditation, and the creation of an accurate HEDIS data set.
Assist in the development of internal physician advisors and provide support in developing solutions for complex cases, in the authorization and denial of services, and in the grievance and appeals process.
Assist in monitoring effectiveness of physician advisors in supporting the care and case management activities.
Assist operation staff in the clinical oversight of subcontracted services and other organizations for which Highmark Wholecare is liable for quality oversight
Effectively interact with professional groups, such as state and county medical societies, hospital executive committees, medical staff executive committees, payers, member related associations, community groups etc.
Participate in presentation of corporate goals and interests to practitioners/providers, community and business groups, social agencies, and government bodies.
Assist in developing Highmark Wholecare's presence in community outreach and service activities and participate in community efforts to understand and control health care costs.
Represent the organization in public affairs and professional organizations, and attend various corporate meetings when requested by the Chief Medical Officer.
Augment CME activities with studies related to management health care, health politics, national and regional changes in the health care environment.
Seek/achieve certification by ABQAURP, ACPE, etc., and maintain up-to-date completion of the physicians' recognition award of the AMA for CME work completion.
Develop and maintain familiarity with applicable State and Federal regulations and NCQA requirements for accreditation.
Develop expertise in a designated area and become a source of consultation for other medical directors and staff throughout the organization.
Maintain regular contact and solicit feedback on performance from management and your peers.
Perform other duties as assigned by the Chief Medical Officer
Other duties as assigned or requested.
Medical staff leadership experience, significant prior experience in health care management roles, and involvement with formal quality and/or utilization management programs are required
5 years of experience as a primary care physician or other valuable medical expertise and current knowledge of the clinical practice concerns and issues
Board certification in a primary medical specialty and a current, unrestricted PA or DE medical license is required
MBA, MPH, MMM or other advanced education in business or public health
Proven ability to manage a project in order to accomplish previously agreed upon goals within a reasonable time period and through the use of developed organization and leadership skills
Excellent communication and public speaking skills, well-developed interpersonal skills, and ability to interact effectively with members, practitioners/providers, colleagues, and local State and Federal agencies
Professional UR/QI training and certification
Observe all applicable laws, regulations, company and divisional policies and procedures, and should approach business decisions with sound personal and professional ethics to reflect Highmark Wholecare's core values, Code of Business Conduct and the Integrity Process
Foster a reprisal free environment to promote open and constructive communication
Demonstrate support of all ethics and compliance initiatives such as participation in the Integrity Process or compliance training and to consistently demonstrate support of Highmark Wholecare's core values, Code of Business Conduct and the Integrity Process through management decision
Shares responsibility for quality with every other member of Highmark Wholecare.
Accountable for identifying quality-related problems and notifying management when they believe quality is being compromised
Expected to recommend process improvements designed to improve accuracy, timeliness of processing, and/or eliminate manual effort required
All Highmark Wholecare employees must meet all CMS and Highmark Wholecare security requirements
All Medicare contractor position descriptions are subject to the Centers for Medicare and Medicaid Services (CMS) security requirement to classify positions as to their sensitivity levels. These levels relate to the impact that the position has on access to Medicare beneficiary protected health information and/or financial information. The designations are high, medium and low sensitivity with each designation having specific background investigation criteria applied to them. The reinvestigation is required to be conducted at least every five years for each position.
Major contacts include the Chief Medical Officer for status of activities, performance evaluation, etc., and should occur as frequently as needed, at least weekly
Other contacts include Vice Presidents and Directors external to the administration area for clinical consultation, status of activities and projects, etc., as needed. Other contacts include various directors of care and case management, clinical program development, consulting services, operations, alliance ventures, marketing, and the health care informatics and research area
There are a variety of external contacts that the Medical Director would be anticipated to regularly contact. These include physicians, practice administrators, specialists, behavioral health providers, ancillary service providers, hospital executives and senior management, various Highmark Wholecare accounts, regulatory agencies, and vendor providers
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company's Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employee's responsibility to comply with the company's Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Pay Range Minimum:
Pay Range Maximum:
Base pay is determined by a variety of factors including a candidate's qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
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Req ID: J223931