• Associate Medical Director

    Job Locations US-RI-Smithfield
    Req No.
    2018-9481
    Department
    Medical Directors Office
    Type
    Regular Full-Time
  • Overview

    Provide clinical support to departments and processes company-wide with the goal of promoting quality, access, member satisfaction and efficiency in health care services.

    This position assists the Medical Director in establishing medical policies. This work entails ongoing monitoring and review of evidence-based clinical data and that of the plan’s utilization patterns, challenges and opportunities. He/she works collaboratively with other departments to ensure effective implementation and integration of clinical policies. In addition, he/she provides medical consultation in support of programs/projects for the effective integration of multidisciplinary services for members across multiple departments.

    Responsibilities

      • Provide clinical expertise to the Medical Review process by
        • guiding development of Clinical Medical Policies and Clinical Benefit Guidelines
        • performing review of medical and pharmacy requests for non-benefit or restricted benefit services
        • engaging providers/prescribers in discussions of medical necessity
        • notifying members and prescribers of decisions
        • participating as a member of the MCAP Advisory Council
        • meeting all regulatory expectations of review processes
      • Participate in program development for existing and new lines of business.
      • Serve as clinical resource to Medical Management for
        • Neighborhood Clinical Guidelines development and maintenance
        • clinical programs (eg Asthma, Diabetes, Bright Start)
        • research and consultation as requested by nurse case managers
      • Provide clinical expertise to the Quality Assurance process by performing review and recommendation for member and provider complaints, and participate as a member of the Quality Assurance Committee in decision for actionable follow-up to complaints.
      • Lead the new technology review process by performing reviews of new technologies or new applications of existing technologies, by chairing the Medical Technology Review Committee and by leading decision-making for addition of new technologies to the list of benefits for members
      • Serve as clinical resource to the Claims department for review and processing of administrative denials
      • Assist in preparation for regulatory and accreditation reviews
      • At the direction of the Medical Director, represent Neighborhood in meetings or other forums with practitioners, regulators, purchasers, etc.
      • Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood’s Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and  the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents
      • Other duties as assigned

       

      Organizational Competencies:

      • Judgment and Decision Making
      • Gets Results
      • Collaboration and Teamwork
      • Business Awareness
      • Customer Focus

       

       

      Job Specific Competencies:

      • Continuous Quality Improvement
      • Organizational Savvy
      • Planning & Organizing
      • Problem Solving & Analysis
      • Strategic Thinking & Alignment

       

      FDR Oversight:

       

      • N/A

    Qualifications

    Qualifications Required:

    • Physician with unrestricted license, willingness to obtain Rhode Island medical license if not currently licensed in RI, no restrictions in any state
    • Minimum of Three (3) years’ clinical practice experience
    • Previous experience with Managed Care Organization (MCO), Accountable Care Organizations (ACO) and/or Centers for Medicare & Medicaid Services (CMS) required
    • Excellent analytical and communication skills

     

    Qualifications Preferred:

    • Previous experience with medical policy
    • Board certified in a primary care or other relevant specialty
    • Ongoing part-time clinical practice

    Neighborhood is an Affirmative Action and Equal Opportunity Employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, genetic information, age, disability, veteran status or any other legally protected basis.

     

    Neighborhood is committed to ensuring individuals with disabilities and/or those who have special needs participate in the workforce and are afforded equal opportunity to apply for jobs. If you would like to contact us regarding the accessibility of our Website or need assistance completing the application process, please contact us at recruiting@nhpri.org

     

    Neighborhood is an EOE M/F/D/V and an E-Verify Employer

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