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Medical Director

Medical Director-Remote
Job Details
Job Type


Remote • UM Care Management
Job Summary

The senior medical director plays a critical role in medical delivery and medical cost management for the company to promote high-quality, responsive care. The medical director will work across the organization and with community physicians to continually develop and drive innovative strategies focusing on improving member health; managing medical costs; and providing clinical expertise for all medical management, care management, disease management, utilization management, pharmacy management, quality improvement, Risk Adjustment, and the Medicare Stars programs. The medical director will provide leadership and help support the functions listed above; create medical policy; and conduct reviews of appeals.

Major Work Activities

Primary medical cost manager and provides guidance and expertise to leadership and others on medical cost controls, claim reviews, appeals, and utilization management
Supports the company’s overall goals by designing and implementing care programs and population wellness programs
Design and implement medical policy and procedure guidelines for providers and utilization review; gaining physician and other clinician support for the implementation of care programs and other initiatives to support high quality, responsive care
Assist the Chair and lead collaborative relationships with clinical committees, including quality, medical management, and medication management to ensure effective communications, as well as, clinical and operational effectiveness
Actively coach, develop, mentor, recognize, reward, and motivate employees to optimize company, team, and individual performance
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Partner with the Enterprise-wide medical directors on best practices for quality care management for the company, Cone Health, Triad Healthcare Network, and other affiliates
Provide education to physicians and other clinicians regarding formulary, quality of care, accurate coding, and other measures to support quality outcomes and meet cost objectives
Collaborate with community physicians and clinicians to promote coordination of care and improve outcomes for members
Assist in public relations functions as appropriate with the medical community
Assist in the oversight of the Medicare Part C and D coverage determinations, appeals, and grievances processes, including the review and adjudication of appeal decisions, medication necessity, prior authorization requests, step therapy exceptions, quantity limit exceptions, tiering exceptions, and non-formulary exception requests
Support the Centers for Medicare & Medicaid Services HEDIS, compliance with URAC and/or NCQA standards, risk adjustment, CAHPS, HOS, and other activities including, preparation for site visits, audits, accreditation, and respond to accrediting and regulatory agency requests
May lead a staff assigned to medical delivery and medical cost management; provides guidance and mentoring of staff, and builds effective teams (both internally and with vendors) to achieve established goals and within established budgets
Demonstrates the ability to lead and influence others positively to achieve desired goals of HTA
Establish and maintain a positive working relationship with shareholders, regulatory agencies, and vendors
Performs other duties as assigned

Minimum Qualifications

Required Education

Doctor of Allopathic Medicine (MD) or Doctor of Osteopathic Medicine (DO)
Required Licensure/Certification

Valid License in North Carolina (or ability to sit for licensure within an agreed-upon time frame)
Required Experience

3+ years previous experience as a medical director
3+ years experience in medical management such as UM, CM, DM, risk adjustment, quality, and pharmacy
Experience and knowledge of HEDIS/CAPHS/HOS/NCQA
5+ years clinical experience
Required Knowledge, Skills, and Abilities

Knowledge of population health care delivery strategies; care management practices, utilization management practices
Strong in the following competencies:

Decision Making/Judgment
Problem Solving/Analysis
Ability to effectively build positive, constructive relationships
Assertive and encouraging communication style
Results-oriented while being flexible and open-minded
Proficient in Word, Excel, and PowerPoint
Preferred Education

Board-certified in internal medicine, family medicine or geriatrics approved by the American Board of Medical Specialties (ABMS) or the American Osteopathic Association Bureau of Osteopathic Specialists (AOABOS) from the major areas of clinical services
Master’s degree in business or related field
Preferred Experience

Health plan experience
Medicare Advantage Special Needs Plans experience
Experience with Medicare Advantage and Part D health plans, products, trends, and markets

Time:  Full time
Salary:  Salary
Category:  Administration

Updated: 6/8/2021 1:39:36 PM

Job Contact:
Michael Abner

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7800 McCloud Road
Greensboro, NC 27409