Meridian Health Plan Medical Director in Detroit, Michigan
More information about this job:
Who we are:
Meridian Health Plan is a family-owned, family-operated company of passionate leaders, achievers, and innovators dedicated to making a difference in the lives of our members, our providers and in the healthcare industry.
We provide government-based health plans (Medicare, Medicaid, and the Health Insurance Marketplace) in six different states (Michigan, Illinois, Iowa, Indiana, Kentucky, and Ohio).
Our employees work hard, play hard, and give back. Meridian employees enjoy: Happy hours, special events, company sports teams, potlucks, Bagel Fridays, weekly Executive Lunches, and volunteer opportunities.
This position provides oversight of the Utilization Management process and assumes responsibilities within the Quality Improvement program.
Respond to provider inquiries regarding utilization management decisions, complaints and appeals. Promote positive provider relationships
Offer clinical insight for the development or adoption of utilization management, pharmacy and quality improvement programs, as well as medical necessity definition and criteria
Review post-service appeals and make appropriate determinations regarding the medical necessity and appropriateness of services
Review practice patterns of physicians and work with the Chief Compliance Officer to identify potential for Fraud Waste and Abuse (FWA) and to report these findings to the Corporate FWA Committee
Investigate complaints from membership in regard to the quality of care they are receiving and to report these findings to the credentials committee
Monitor compliance with physician credentialing and re-credentialing policies and procedures. Review “clean” files and prepare exception report prior to Credentialing Committee meeting
Serves as a member on the Policy Committee, as well as develops policies
Serves as a contact to meet with providers to review physician Quality and UM issues, as well as data sharing, PIPs, etc.
Serves as a contact to meet with vendors for possible contract opportunities
Coordinate with the Chief Medical Officer, the Pharmacy Director and the health plan’s pharmacy benefit manager to ensure appropriate administration of the pharmacy benefit
Provide clinical oversight and decision making regarding CSHCS applications
Oversee the care coordination ABAD teams
Oversee the Transplant team, including evaluation and transplant reviews, policies, data gathering and sharing reporting to MERC/CMO
Provides oversight and direction for Prolong Length of Stay and Hospital Care Coordination Team
Provides educational lectures to Care Coordinators, as well as other staff
Assure MHP compliance with all regulatory programs including National Committee for Quality Assurance (NCQA), URAC or general accreditation and State Medicaid guidelines
Assist with writing IRO’s and address RFPs/RFIs as needed
Assist with operational/project management as needed. This includes: community outreach for care coordination teams, previous implementation of project BOOST, PASS, MISTARR, and care transitions
What you can bring to Meridian:
Current unrestricted license as Doctor of Medicine or Osteopathy is required
Current board certification in his or her designated specialty is required
5 years Post Graduate experience in direct patient care
Experience in providing care to a Medicaid population
Knowledge of utilization management, quality improvement, and accreditation standards of the National Committee for Quality Assurance (NCQA) and the Healthcare Effectiveness Data and Information Set (HEDIS)
What Meridian can offer YOU:
Our healthcare benefitsinclude a variety of PPO plans that are effective on the first day of employment for our new full-time team members.
Meridian offers 401k matching thatis above the national average.
Opportunities for growth are abundant; full-time MHP employees are eligible for tuition reimbursement and all employees have access to a variety of training through Meridian University.