JOB SUMMARY
Medical Director plays a critical role in assuring that the Utilization Management (UM) program is running well, is focusing on the highest value opportunities and has an effective prior authorization program and Medical Review Guidelines (MRG). The Medical Director is a leadership role within the Medical Director Group and has the ability to positively influence the Associate Medical Directors. The Medical Director reports to the Senior Medical Director and works with him/her collaboratively to ensure the Prior Authorization and concurrent reviews are done efficiently and effectively and are evidence-based. In addition, the Medical Director will work on committees and projects as assigned and will be able to advise on coding issues and medical necessity as requested.

JOB SPECIFICATIONS AND CORE COMPETENCIES

• Assists the SVP of Medical Affairs in working with Provider Relations to maintain and improve relationships with contracted providers, including issues related to claim payment, chronic care management, and general utilization management. This may also include visits to high volume providers, and review of provider incentive plan payments.
  
  
• Performs medical necessity determinations and appeals of adverse determinations utilizing evidence-based guidelines and/or plan specific policies. Includes pre-certification, retrospective, concurrent, and claim reviews).
  Performs benefit (not covered, out-of-network, etc.) determinations and appeals utilizing appropriate line of business benefits.
  Performs peer to peer interventions for all aspects of medical management.
  Engages in state Fair Hearings as required.
  
  
• Provides clinical oversight support for medical management activities related to utilization management, case management, disease management, quality improvement, credentialing, and preventive medicine.
  Provide clinical support on plan operational policies, processes, and procedures, (ex. BCC and UAs).
  Provide clinical support on interdepartmental projects
  Assist in developing an effective and efficient Prior Authorization list for each line of
  business.
  
• Assist in reviewing explanation of coverage for each line of business.
  
• Develop, review, and implement plan medical policies and other medical decision-making policies or procedures.
  Develop physician education with respect to clinical issues and policies through letters and articles in provider newsletter and other publications.
  Develop written information to members through letters and articles in member newsletters and other publications.
  
• Provides clinical guidance and support to initiatives that address public health issues. (Ex. COVID back to work initiative; syphilis epidemic).
  Participation on Member Complaint Appeal Panel.
  
• Attends or chairs committees as required such as FWA and others to achieve medical utilization, cost, and quality objectives as directed by VP of Medical Affairs.
  Assist in establishing collaborations with community organizations (such as Pathways Community HUB, and other mental health programs; MOD doula; HCPH Access Program).
  
  
• Actively contributes to achievement of departmental goals, as identified in departments annual business plan, including specific departmental process improvement plans.
  Other duties as assigned.
  
  
  QUALIFICATIONS:
  
• Education/Specialized Training/Licensure: Board certified physician and licensed in Texas required.
  
  
• Primary Care Specialties preferred.
  
  
• Work Experience (Years and Area): 5-7 years in active practice required.
  
  
• Prior managed care experience preferred.
  
  
• Management Experience (Years and Area): Has minimum of 4 years of experience in utilization management (UM), and medical policy development.
  
  
• Coding expertise and experience in managing network physicians
  
  
• Software Proficiencies: Proficient in office software; must be able to become proficient in clinical information systems
  
  Prior experience with clinical information systems such as Jiva; experience with data analysis