Meridian Health Plan Medical Director in Detroit, Michigan

Medical Director

Job ID

2016-4043

Job Location

US-MI-Detroit

Category

Medical Management

Business Line

CMC Corporate

More information about this job:

Overview:

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.

Responsibilities:

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

Qualifications:

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.