The Medical Director is actively involved within Farm Bureau Health Plans in the fields of quality assurance/quality improvement, benefits management, community relations, and case management and serves as a medical professional resource in support of other divisions of FBHP. This position will have responsibilities with all Farm Bureau Health Plan products, including under 65 plans, Medicare Part D and Medicare Advantage programs. The Medical Director reports directly to the Chief Medical Officer.
Education: Degree in Medicine, either M.D. or D.O., from an accredited school, current Board Certification in an ABMS or AOA recognized specialty, and active, unrestricted Tennessee State Medical License required.
Work Experience: 5+ years’ clinical experience with Managed Care Health Plan/Payer experience and demonstrated knowledge of Managed Care products and strategies.
GENERAL RESPONSIBILITIES : Quality Assurance/Quality Management: Assists Quality Management staff in design of quality improvement studies as requested. Participates in medical review assessments (e.g., NCQA).Identifies problems, situations, or providers requiring focused reviews. Provides support to delegated organizations to achieve program goals. Provides medical input into projects related to HEDIS.
Medical Policy and Technology Evaluation: Participates in the Policy and Protocol Committee for identification and discussion of medical policy issues. Strives to attain consensus in the community regarding medical policies. Consults with peer review groups and other plans as necessary. Participates actively in additional meetings and health system Joint Operating Committees as necessary.
Case Management: Provides support to delegated organizations to achieve program goals. Supports and advises case managers regarding high-risk medical problems.
Utilization Management: Provides support to delegated organizations to achieve program goals. Reviews precertification, concurrent and retrospective requests for services that do not meet medical criteria for approval. Performs proactive & reactive peer-to-peer discussions. Serves as a resource to the delegated Utilization Management staff in reviewing data and recommending realistic strategies to achieve cost savings. Reviews and analyzes utilization data for cost containment strategies and appropriateness of care. Reviews and analyzes data for under- and over-utilization. Represents utilization management on other committees as necessary. Works to achieve internal customer satisfaction and regulatory/accreditation agency compliance goals by assuring both timely turn-around of coverage reviews and quality outcomes based on those review decisions. Awareness of clinical appeal process as appropriate and supports the CMO in this activity when necessary.
Other Responsibilities: Assists the CMO in oversight of all Health Services delegated services. Participates in Plan committees (e.g. QM, grievance/appeals committees, PAC). Supplies medical input into out of area contract negotiations. Identifies legal issues of concern to FBHP Legal department. Serves as medical consultant for Legal Counsel and Special Investigations Unit. Performs other duties as assigned by the CMO.
The Medical Director must also maintain a current knowledge of applicable federal and state laws and regulations, including industry best practices. During lawful compliance reviews or investigations, the Medical Director will cooperate with the appropriate regulatory entities.
Strong written, verbal and interpersonal communication skills. Ability to effectively interface with various internal and external entities, including physicians, physician organizations and hospital management.
Valid driver’s license for regional travel.
Consistently demonstrates high standards of integrity supporting the mission, values and adhering to the Corporate Code of Conduct.
Maintains high regard for member privacy in accordance with corporate privacy policies and procedures.
Ensures all activities comply with relevant legislative and regulatory mandates.
Ability to manage multiple priorities independently.
Demonstration of strong and effective abilities in teamwork, negotiation, conflict management, decision-making and problem-solving skills.
Successful experience and comfort with change management demonstrating sensitivity to culturally diverse situations, participants and customers/members.
Competitive Compensation target 275-290k
Significant Growth Potential
For confidential discussions, contact: Molly Bilisoly, Executive Director, Healthcare Executive Connections 757.652.1141. Email resume with reason for interest to: firstname.lastname@example.org or email@example.com
MD/DO Board certified in medical specialty
Active, Unrestricted TN medical license desired upon hire.
Adult patient care and health plan medical management skills.
Strong Interpersonal, Listening, Leadership, Diplomacy, Analytical, Negotiating Skills, High Energy, Collaborative Team Building, Adaptability and Problem Solving Skills in Changing Environments with Unwavering Moral and Ethical Values. Knowledge of The Business of Health Care to Support of Health Insurance for Special Needs Participants to Improve Quality of Affordable Population Health Care.
UM, QI and Provider, Vendor and Regulatory Relations, Outcomes Measurement, Peer to Peer Reviews, Medical Policy, Chronic Care Program Management in Medicare Advantage products.
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