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Our mission is to enhance well-being by connecting individuals with vital health resources through a compassionate workforce that embodies the spirit of neighbors helping neighbors.
HealthOne is guided by a cultural framework that embodies our values and drives our decisions.
Our PURPOSE is to care for people by connecting them to resources that help protect them in health related situations. To fulfill our purpose, we align our PRIORITIES to ensure each decision we make is ethical, empathetic, economical, and efficient. We care for PEOPLE by being welcoming, authentic, truthful, consistent, and humble. We are continuously looking for ways to improve our PROCESS and how we get things done.
HealthOne seeks individuals with integrity and heart to embody our values. Whether you’re starting your career or looking to develop additional skills to reach your full potential, HealthOne provides the means to help you achieve your goals.
Provides clinical leadership and serves as an internal medical consultant to various divisions and committees to support the development, implementation and monitoring of medical management and quality improvement activities.
ESSENTIAL JOB DUTIES
• Provides professional leadership and direction on clinical quality management, utilization, and cost management.
• Collaborate and interface with providers as necessary and requested by HealthOne Alliance.
• Assist is strategic planning for HealthOne Alliance programs.
• Provide medical direction on cost utilization trends and work to develop related cost containment strategies.
• Assist in designing and implementing medical policies, goals, and objectives.
• Maintain current knowledge on all legal and regulatory requirements impacting the Medical Management and Pharmacy Services departments.
• Review patient medical records and treatment plans and provide clinical insight regarding same.
• Assist in creating and maintaining an organizational system that gives feedback to and accepts feedback from providers and organization participants.
• Participate in policy review and make recommendations on same.
• Support NCQA and other certification and qualification activities as necessary.
• Support utilization management process to include all levels of medical necessity and/or administrative review as applicable within regulatory requirements.
• Conduct and participate in quality management and outcome studies as directed.
• Participate in the development of collaborative initiatives between the Medical Management, Pharmacy Services, Quality Improvement and Risk Adjustment Departments.
• Oversee other medical staff and medical training as necessary.
• Represent HealthOne Alliance at medical group meetings, conferences, etc.
• Support the creation and implementation of Value Based Care financial arrangements and incentive programs.
• Participate in the inter-reviewer reliability process as a reviewer to help ensure medical necessity determinations are consistent with MCG criteria and /or medical policy guidelines.
• Assist in development and administration process of inter-reviewer reliability methodology as needed with staff to ensure medical necessity determinations are consistent with MCG criteria and /or medical policy guidelines.
• Analyze, evaluate, and apply clinical metrics that produce actionable information in support of medical management and quality improvement initiatives.
• Direct and support physician review to ensure timeliness, accuracy and reliability of UM and Appeals reviews.
• Lead and serve on various committees in order to accomplish medical utilization, cost and quality objectives of HealthOne Alliance.
• Willingness to travel within the State of Georgia and nationally.
• Maintains regular and predictable attendance.
• Consistently demonstrates compliance with HIPAA regulations, professional conduct, and ethical practice.
• Works to encourage and promote Company culture throughout the organization.
• Other duties may be assigned.
• Current MD or DO degree with an unencumbered and unrestricted license to practice medicine in Georgia and Tennessee required
• 5 years - Clinical experience required
• 5 years - Healthcare administration, including UM experience highly preferred
• Experience in internal medicine, family medicine or emergency medicine required
• Experience in specialty areas such as oncology, rehabilitation, and physical medicine preferred
• Board Certification in a recognized specialty by the American Board of Medical Specialties or the American Board of Osteopathic Specialists
• Ability to conceive and deliver innovative solutions
• Ability to perform complex problem solving
• Ability to work independently with minimal supervision or function in a team environment sharing responsibility, roles, and accountability.
• Outstanding negotiation, presentation, and facilitation skills
• Proficient in Microsoft Office (Outlook, Word, Excel and Powerpoint)
• Ability to interpret and explain complex government policies
• Knowledge of health plan operations and utilization management strategies
Prolonged periods of sitting at a desk and working on a computer. Moderate to significant amount of stress in meeting deadlines and dealing with day-to-day responsibilities. Must be able to drive a vehicle and daytime/overnight travel as required.
401K (4% Match, Immediate Vesting)
Critical Illness Insurance
Employee Assistance Program
Flexible Spending Account
Health & Wellness Program
Health Savings Account
Life & AD&D Insurance
Long Term Disability
Paid Time Off
Short Term Disability
Drug Screen and Background Check Required
HEALTHONE IS AN EQUAL OPPORTUNITY EMPLOYER
All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, disability, sex, age, ethnic or national origin, marital status, sexual orientation, gender identity or presentation, pregnancy, genetics, veteran status, or any other status protected by state or federal law.
Time: Full time
Updated: 9/6/2023 6:52:59 AM