MEDICAL DIRECTOR, GOVERNMENT PROGRAMS-SOUTHEAST
The French Group has been exclusively retained to assist our client, a progressive and highly respected health plan, in hiring a physician executive for this newly created position. The Medical Director Government Programs will work closely with the existing team of talented physician executives in helping to define and articulate the clinical leadership and innovative strategies of this dynamic organization. The primary responsibilities of this role include providing clinical support and direction for Care Programs for the Medicare and Exchange Products, as well as providing Medical Director expertise to the Transitional Care, Condition Care and Specialty Case Management programs.
The Medical Director reports to the Senior Medical Director, a seasoned physician executive with a calm demeanor, analytic mind and approachable, team-oriented management style.
ADDITIONAL ESSENTIAL FUNCTIONS:
- Lends medical expertise to the development and evolution of the Care Programs that support the Medicare and Exchange Products
- Collaborate in the development of Condition Care, Transition of Care and Specialty Case Management Care Program strategies.
- Support the implementation of product focused initiatives for the Exchange.
- Conduct care coordination activities supporting case management and condition management programs.
- Performs medical director reviews for Medicare Appeals, as well as UM Review as needed.
- Review utilization, appeal and case management metrics monthly and discuss with Care Management team and report outward.
- Review and adjudicate possible adverse benefit determinations involving clinical review
- Collaborate with other Medical Directors to discuss trends in local delivery system and support resolution of issues.
- Support corporate projects and initiatives as needed
- Support Network, Quality, Medical Policy, and Credentialing as needed.
- Make recommendations for clinical product and program development and identify opportunities for improvement of clinical outcomes.
- Participate in governance through committee attendance and chair committees as needed.
- Build trust by demonstrating high ethical standards and personal integrity and implement strategies aligned with the Plan’s mission.
- Maintain and develop relationships with key thought and business leaders in the health care delivery marketplace.
The Medical Director is a critical medical and business leader for internal clinical teams and may serve as needed, a contact for external providers, plan sponsors, and regulatory agencies; thus requiring superior interpersonal, negotiation, influencing and presentation skills. The successful candidate will also have the respect of her/his peers and credibility as a clinician with extensive experience in private practice. At least three years’ experience in managed care, utilization review and/or quality management is desirable.
Additional attributes of the ideal candidate:
- Knowledge of health benefits industry, products, trends, consumer market, competitive intelligence, and legislative climate with a minimum of 2 years in an administrative role
- Strong analytic and problem solving skills
- Innovative thinker with ability to manage projects and drive program development
- Understanding and proficiency in use of metrics and measures in managing programs and services
- Commitment to high service standards and a passion for making positive changes within the organization and the healthcare system
- Works collaboratively and encourages cross functional thinking
- Recognizes complexity of managing the needs of multiple customers (plan sponsors, members, providers, brokers and consultants) and proactively identifies those needs
- Highly organized and prioritizes multiple tasks with impeccable follow through
- Experience and expertise in medical cost reduction activities
- Knowledge of care delivery options
- Experience with medical policy and application of criteria
- Grievance and Appeals Management experience
- Strong Medicare Advantage and Commercial Product experience
- Understanding of compliance requirements
- MD or DO degree from an accredited medical school
- License to practice medicine in the state of Florida without restriction, or ability to obtain.
- Current Board Certification in an ABMS/AOS recognized specialty – primary care preferred
- MBA or MPH preferred
For additional information and/or confidential consideration, please contact:
CONSULTANT: Tricia French, RN, BSN
President & CEO
The French Group