JOB SUMMARY

The Medical Director, Appeals and Grievances provides leadership for Community Health Choice medical management programs. This includes reviewing appeals of adverse determinations, tracking them and providing feedback to Medical Affairs on current overturn trends. In addition will provide clinical input and oversight for Care (Disease) Management, Quality Improvement, Credentialing, and Preventive Health programs. Will work with Provider Relations to maintain and improve relationships with the provider community especially with Value based arrangements. Will perform medical necessity reviews as assigned including reviews with peer-to- peer interactions as needed and other duties as assigned.

JOB SPECIFICATIONS AND CORE COMPETENCIES

• Performs medical necessity reviews for appeals of adverse determinations utilizing evidence-based guidelines and/or plan specific policies. Assists Appeals staff with consultation on appeals including determining need for and selection of a specialty reviewer and monitors and reports overturn trends for all lines of business.
• Assists the Vice President, Sr. Medical Director of Medical Affairs in working with Provider Relations to maintain and improve relationships with contracted providers especially those in value-based arrangements with Community. Provides expert help to provider relations to resolve 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.
• Provides clinical oversight support for care (disease) management, quality improvement activities, credentialing, preventive medicine.
• Performs peer to peer interventions for all aspects of medical management.
• Actively contributes to achievement of departmental goals, as identified in
• departments annual business plan, including specific departmental process improvement plans, and other duties as assigned.

QUALIFICATIONS:

• Education/Specialized Training/Licensure: MD or DO Degree and Licensure in the State of Texas, Completion of Residency and Board Certification with preference for the Primary Care Specialties required.
• Masters degree in public health, Business Administration or Medical Administration preferred.
• Work Experience (Years and Area): Three years clinical experience with two years of prior experience as physician reviewer or medical director in a managed care organization or health plan.
• Management Experience (Years and Area): 1-2 years of management experience preferred.
• Software Proficiencies: Microsoft Office (Word, Excel, Outlook)