This job was posted by https://idahoworks.gov : For more information,please see: https://idahoworks.gov/jobs/2153005 Surgical AssociateMedical Director or Medical Director (DOE)

　　Remote in ID, OR, WA, UT

　　*Experience in a surgical specialty and/or coding experience isrequired*

　　These roles will participate in utilization management, provide clinicalleadership and support to clinical teams to ensure our members receivequality, cost effective care yielding optimal outcomes.

　　General Functions and Outcomes May Include:

　　Provides clinical leadership for staff to ensure members receivesafe, effective and cost efficient services.Contributes to the development of various medical managementstrategies and tactics to drive results and achieve key performancemetrics.Conducts peer clinical review for medical necessity on utilizationmanagement authorization requests.Provides clinical input on case management reviews working closelywith the CM clinical staff.Responsible for discussing review determinations with providers whorequest peer-to-peer conversations.Participates on multiple teams to provide clinical input on medicalpolicy reviews and development and may participate on committeesthat develop programs impacting clinical interventions, utilizationmanagement and case management.Analyzes and uses data to guide the development and implementationof health care interventions that improve value to the member andemployer.Advises Health Care Services Leaders on related key performancemetrics and the effectiveness of various efforts, initiatives,policies and procedures.Identifies and communicates new opportunities in utilizationmanagement, provider contracting or other areas that would enhanceoutcomes and the reputation of the organization.Provides clinical expertise and coordinates between internalclinical programs and providers of care to improve the quality andcost of care delivered to health plan members.Ensures ethical decision making in compliance with contractualarrangements, regulations and legislation.Supports internal communication or training that ensures service isprovided to members and providers by a well-trained staff.Promotes provider understanding of utilization management andquality improvement policies, procedures and standards.Provides guidance and oversight for clinical operational andclinical decision-making aspects of the program.Has periodic consultation with practitioners in the field andensures that the organization has qualified clinicians accountablefor decisions affecting consumers.May manage staff including hiring, performance management,development and retention.May participate in health plan credentialing operations and clinicalaspects of the credentialing program and provider services support.Minimum Requirements

　　Demonstrated competency working with hospitals, provider groups orintegrated delivery systems to effectively manage patient care toimprove outcomes.Strong communication and facilitation skills with internal staff andexternal stakeholders, including the ability to resolve issues andseek optimal outcomes.Proven ability to develop and maintain positive workingrelationships with community and provider partners.Knowledge of the health insurance industry, state and federalregulations, provider reimbursement methods and evolving accountablecare and payment models.General business acumen including understanding of market dynamics,financial/budget management, data analysis and decision making.Strong orientation to the application of data in managing health andquality.Proven ability to develop creative strategies to accomplish goals and objectives, plan and execute complex projects and programs anddrive results across internal teams and/or external partners.Demonstrated ability to effectively lead and engage in aconstructive manner with others.N

　　o

　　rmally to be proficient in the competencies listed above

　　Associate Medical Director would have a MD or DO degree, at least 3years clinical experience, or equivalent combination of education andexperience.

　　Medical Director would have a MD or DO degree, at least 5 years clinicalexperience, plus at least 2 years medical utilization management and/orcase management experience (prefer health insurance experience andadditional MHA or MBA training), or an equivalent combination ofeducation and experience.

　　Required Licenses, Certifications, Registration, Etc.

　　Licensed Physician with an MD or DO degree. Active, unrestricted licenseto practice medicine in one or more states or territories of the UnitedStates, With one of these licenses in our four-state area (OR, WA, ID,UT). Applicant must also live in four state area. Board Certificationrequired. Qualification by training and experience to render clinicalopinions about medical conditions, procedures