Position Title: Medical Director
Work Location: Remote
Assignment Duration: 6 Months with potential to extend or convert
Work Schedule: Typically work 8-5 pm at their local time zone however sometimes work will go beyond 5 pm if the day’s work is not done. Day may vary.

Position Summary: Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit.

Key Responsibilities:

• Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities.
• Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality decision making.
• Supports effective implementation of performance improvement initiatives for capitated providers.
• Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members.
• Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.
• Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership.
• Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes.
• Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals.
• Participates in provider network development and new market expansion as appropriate.
• Assists in the development and implementation of physician education with respect to clinical issues and policies.
• Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components.
• Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care.
• Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality.
• Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment.
• Develops alliances with the provider community through the development and implementation of the medical management programs.
• As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues.
• Represents the business unit at appropriate state committees and other ad hoc committees.
• May be required to work weekends and holidays in support of business operations, as needed.
• For NH Substance Use Disorder Physician: Provides clinical oversight and guidance for the MCO on Substance Use Disorder issues, including issues such as the use of ASAM or other evidence-based assessments and treatment protocols, the use of MAT, engagement with PRSS, and discharge planning for members who visit an ED or are hospitalized for an overdose.
• Consults on MCO clinical policy related to Substance Use Disorders and the cases of individual members for the MCM program on a routine basis.
• Performs other duties as assigned.
• Complies with all policies and standards.

Qualification & Experience:

• Medical Doctor or Doctor of Osteopathy. Utilization Management experience and knowledge of quality accreditation standards preferred. Actively practices medicine. Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is advantageous. Experience treating or managing care for a culturally diverse population preferred.
• License/Certifications: Board certification in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Association’s Department of Certifying Board Services. (Certification in Psychiatry specialty Is required.) Current state license as a MD or DO without restrictions, limitations, or sanctions from government programs.
• Required: Active Board Certification in Internal Medicine or Family Medicine.

Candidate Requirements
Education/Certification	Required: Active Board Certification in Internal Medicine or Family Medicine.			Preferred:
Licensure	Required: FL, TX			Preferred: , AZ, DE, IA, SC, OH, IL, MI
Years of experience required Disqualifiers Best vs. average Performance indicators		Must haves:  Medicare UM experience, IQ/MCG experience   Nice to haves: Appeals IP experience/knowledge, IMLCC or willing to get it   Disqualifiers:  No active board certification or inpatient clinical experience   Performance indicators:  >90% audit pass score, Productivity > 45 cases per day
Top 3 must-have hard skills Level of experience with each Stack-ranked by importance Candidate Review & Selection		1	Medicare UM experience
		2	Knowledge about Interqual and MCG
		3	Team player, hard worker, collaborative

 
 
At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position’s starting pay is: $ 110.00/hr.