Medical Director Health Plan - Per Diem

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Position Summary

The Associate Medical Director provides professional leadership and direction to the utilization & cost management and clinical quality management functions of Martin’s Point’s Health Plans.

He/She works collaboratively with other plan functions that interface with medical management such as provider relations, member services, benefits & claims management, Health Plan informatics and Health Plan compliance.

He/She also assists in short and long-range program planning, quality management, and external relationships.

The Associate Medical Director reports to the Health Plan Medical Director, has a dotted line relationship to the Vice President of Health Management, and works closely with the Director of Health Management and other Health Plan leaders.

Job Description

Key Outcomes:

Responsible and accountable to the Health Plan Medical Director for helping to manage health plan medical costs and assuring clinically appropriate health care delivery for health plan products and services. Works with the Supervisor of Health Management Clinical Review to plan, organize, and direct the medical and benefits review component of individual case reviews for primary and specialty services for inpatient and outpatient review programs.

Determines and enforces medical necessity of Plan-covered services (benefits).

Serves as a key implementer of the Health Plan’s Triple Aim strategy, vigorously and accurately driving the cost management component of the Triple Aim.

Responsible for assuring physician coverage for the Health Plans and arranging back up during times of absence or vacation.

Assists in the construction of the annual Utilization Management, Care Management, and Disease Management Program Descriptions and works with Health Plan Quality and Health Management leadership to ensure the programs meet accreditation and regulatory standards (e. g. NCQA, CMS, TRICARE) and are properly communicated.

Works with Informatics, Network Management leadership, the Health Plan Medical Economics Strategist to create and maintain a system where Network providers are properly assessed in regard to cost management and develops a plan and schedule for communication with outliers.

• Develops an in-depth understanding of ACOs and contributes to their management and strategic deployment.
• Designs and implements corrective action plans to address issues to improve plan and network managed care cost performance.
• Participates in policy review, policy development, and performs policy analysis and makes recommendations.
• Participates in the retrospective review and analysis of plan performance from summary data of paid claims, encounters, authorization logs, complaint and grievance logs, and other sources.
• Provides support to Health Plan risk adjustment activities as needed.

Is conversant with Health Plan goals and strategic initiatives, in particular utilization and cost management goals, MLR (budget vs. actual and performance versus prior years), inpatient days/1000, SNF days/1000, and clinical quality improvement (QI) objectives, including HEDIS.

Participates in risk management, claims adjudication, pharmacy utilization management, catastrophic case reviews, triage, nutrition service review, case management, provider network support, and credentialing.

Education/Experience

Board certified physician with post-graduate experience in direct patient care required

Active and unrestricted license to practice medicine in Maine or New Hampshire; or another U.S. state with eligibility to apply for and obtain additional state licensure.

• Medical leadership in, or focused activity of, a Health Plan (preferred)
• Knowledge of process improvement tools
• Experience in management preferred

Skills/Knowledge/Competencies (Behaviors)

• Demonstrates an understanding of and alignment with Martin’s Point Values.
• Deep knowledge and practical understanding of Health Care systems and Managed Care concepts
• Knowledge and deep commitment to performance based Health Plan systems
• Good analytic skills with the ability to identify meaningful trends and targets for improvement
• Excellent interpersonal skills and demonstrated ability to establish rapport and working relationships with providers, service vendors and internal staff
• Demonstrated ability to manage and develop staff
• Willingness to explore innovative methods of providing medical management
• Supports the culture and models the MPHC values

Pay Range: $100.21 - $123.78 The pay range above reflects the anticipated base pay range based on a full-time position. Actual compensation will be determined based on factors such as experience, skills, qualifications, and other job-related considerations. Employees may also be eligible for additional compensation, including incentive or commission-based programs, where applicable and subject to the terms of the relevant plan.

This position is not eligible for immigration sponsorship.

We are an equal opportunity/affirmative action employer.

Martin's Point complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact jobinquiries@martinspoint.org

Do you have a question about careers at Martin’s Point Health Care? Contact us at: jobinquiries@martinspoint.org