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Buffalo, Rochester, Syracuse, Utica
The Medical Director participates in the broad array of activities of the Medical Services area including Medical and Pharmacy Utilization Management, quality management, case management, credentialing, and corporate medical policy processes. The incumbent also provides input into the development of policies, programs and strategic objectives that cover Medical Management Services, and acts as a liaison with local physicians and hospitals, and keeps abreast of medical policies and procedures within the medical community.
• Assists the Medical Services Department with Utilization Review and Case Management activities. These activities do not, in any way, constitute practicing medicine.
o Reviews and makes recommendations and/or decisions on Utilization or Case Management activities; utilization review activities include reviews of requests for broad range of medical services including medications at first level, appeal and inquiries.
o Makes accurate and consistent interpretation of integral medical policy, contract benefits and State and Federal Mandates and maintains current and working knowledge of Utilization Management Standards.
o Clinical skills are excellent and evidence based medicine skills are such that the individual provides review oversight for a broad array of clinical services.
• Reviews and makes recommendations on medical policies, guidelines and medical criteria.
• Provides input into the utilization management program policies and procedures.
• Assists with training medical director colleagues, nursing staff including leadership of teaching grand round activities.
• Assists the staff during high peak activity or staff outages.
• Act as a resource to legal counsel; and provides testimony in legal proceedings as required.
• Maintains professional contacts with local Physician community and keeps abreast of medical and managed care trends.
• Attends medical policy, medical director meetings and staff grand rounds meetings
• Take week-end call, as assigned.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values and adhering to the Corporate Code of Conduct.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.
• The position is considered an exempt employee status with an expectation to work those hours which are required to accomplish the work deliverables including occasional evenings during high volume periods and staff shortages (e.g. cross coverage vacations).
• Work from home is an option with an expectation of full compliance with the corporate ‘Work from Home’ policy
Level II – Performs similar functions as level I, plus:
• Reviews medical literature and applies evidence based principles using high proficiency skills.
• Reviews internal trend reports to assess present and future needs and opportunities.
• Interacts with regulatory and accreditation agencies as assigned.
• Medical Degree (MD) required.
• Active unrestricted medical license; appropriate and current board certification.
• A minimum of ten years medical experience and strong working knowledge of QM/UM and credentialing activities.
• Ability to identify, analyze and resolve complex medical issues.
• Skills in evidence based medicine.
• Strong interpersonal skills essential for communication to staff at all levels of the organization.
• Basic skill sets in electronic communication systems such as e-mail and Word.
Level II – requires similar qualifications as level I, plus:
• Superior evidence based medicine skill set
• Strong interpersonal skills essential for communication to physicians in the community.
• Strong verbal presentation skills to lead internal and external discussions at board.
• Advanced skill sets in electronic communication systems such as e-mail, Word, PowerPoint, and Excel.
The Physician is not the subject of any pending professional disciplinary action impairing his/her ability to practice medicine.
In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.
Equal Opportunity Employer
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