The Vice President of Medical Management is responsible for the overall operations of the First Choice Health Medical Management department as well as the implementation of optimization of medical management services. In addition to strategic leadership duties, they will be responsible for providing oversight of Utilization and Case Management staff. The VP role will be remote.
Assist with TPA and PPO line of business expansion by participating in such activities as marketing, new product development, RFP application and benefit plan document production process as appropriate.
Provides clinical and administrative oversight for TPA and PPO with matters concerning quality, UM, patient satisfaction and risk management.
Oversight of medical committees and other work groups such as the Population Health, Medical Advisory Committee, Quality Improvement Council, FCH Operations Committee, and the Credentialing Committee to assure continuous momentum in utilization management and quality activities.
Works closely with management on development of policy/ guidelines for medical management activities.
Provide clinical oversight and guidance to claims, compliance and benefit set-up to assure accurate reimbursement of claims based on medical necessity, benefit plan documents and Medical Policy guidelines.
Responsible for assuring readiness for URAC and other accreditation or licensing agencies.
Assist in preparing ongoing clinical quality projects and implementing new quality improvement strategies.
Facilitate the clinical quality program, including but not limited to, disease management, gap interventions, concurrent review rounds and inter-rater reliability audits.
Oversees Appeals and Grievance process for all lines of business.
Responsible for the annual review/updating of MM policies and procedures.
MD or DO, with at least 5 years of clinical experience, with associated health plan, medical utilization management and/or case management experience or equivalent combination of education and experience.
Demonstrated competency working with hospitals, provider groups, or integrated delivery systems to reduce healthcare costs and improve outcomes.
Excellent communication, influencing, presentation and facilitation skills with all levels of the organization and executive-level external partners, including the ability to creatively resolve complex issues, build consensus among groups of diverse stakeholders.
Proven ability to develop and maintain positive working relationships with provider, vendor, community and account partners.
In-depth knowledge of the health insurance industry, state and federal regulations, provider reimbursement methods and evolving accountable care and payment models. Proven capabilities to drive change related to population health and healthcare transformation.
Strong knowledge of health plan clinical practices, programs and processes.
General business acumen including understanding of market dynamics, financial/budget management, data analysis and decision-making. Expertise in applying data and best practices to manage health and quality outcomes.
Proven ability to develop creative strategies to accomplish goals and objectives, plan and execute complex projects and programs, and drive results across internal teams and/or external partners.
Ability to effectively coach and manage others. Experience driving change and managing deliverables.
Extensive experience supporting and advising for Medicare business. Preferred experience with a health plan
Become a First Choice Health employee and enjoy our generous benefit package. We offer competitive benefits that are much beyond the traditional basics.Click here to learn more about our competitive benefit package.
How to Apply
Please submit your resume to [email protected].
Additional information about our company may be found on our website www.fchn.com