Medical Director - Benefit/Utilization Management

Medical Director - Benefit/Utilization ManagementThis position is responsible for oversight of clinical and wellness programs and initiatives in support of CareOregon members. Areas of focus may include benefit management, benefit utilization, quality assurance, case management, disease management, pharmacy, or other areas.

Note: This is a 0.8 position with benefits. The hiring range listed would be pro-rated to reflect 0.8. Estimated Hiring Range:
$294,570.00 - $360,030.00 Bonus Target:
Bonus - SIP Target, 10% Annual
Current CareOregon Employees: Please use the internal Workday site to submit an application for this job.
Essential Responsibilities

- With the Senior Medical Director, develop, implement and manage clinical and wellness programs to address the needs members.

- Implement, direct and oversee utilization, case, disease, and/or quality management programs.

- Develop and implement programs for educating participating physicians regarding quality management and utilization management issues.

- Represent the health plan in applicable activities including medical and other professional organizations.

- Participate in activities that enhance CareOregon’s image within the community.

- Serve as a representative and medical spokesperson for the plan in support of Coordinated Care Organizations (CCOs), contract negotiations and other provider expansion activities.

- Provide leadership necessary to maintain a motivated, productive and competent team through open communication and delegation of responsibilities and authority.

- Provide medical support for Care Management/Care Coordination activities.

- Provide medical director oversight, benefit determinations and appeals for medical and pharmacy as assigned by Senior Medical Director.

- May integrate with CCO/Line of Business (LOB) Medical Directors to develop, implement, direct, and oversee programs that provide clinical strategy and interventions to CCO/LOB clinical systems.

- Support and implement programs for educating network providers regarding best clinical practice using of population/panel management and performance data on clinical quality and utilization.

Experience and/or Education
Required

- Board-certified medical doctor or doctor of osteopathy in one of the primary care specialties, including obstetrics/gynecology (Internal Medicine, Family Practice, Emergency Medicine, or Pediatrics preferred)

- Licensed physician (MD or DO) in the State of Oregon

- Minimum 3 years’ physician experience

Preferred

- Minimum 4 years’ experience in a supervisory position

- Benefit/utilization management experience

- Leadership experience, preferably to include managed care, quality assurance, utilization review and case management experience

Knowledge, Skills and Abilities Required
Knowledge

- Clinical knowledge of the management of diverse medical problems

- Basic knowledge of applicable regulatory and contractual requirements for Medicaid, Medicare and commercial insurance

- Understanding of managed care operations

- Familiarity with guideline development, outcomes management, population health improvement, disease management and cost effectiveness and cost analysis studies

- Awareness of physician/provider payment issues, physician practice models and total quality and continuous quality improvement concepts

Skills and Abilities

- Medical policy knowledge and skills as related to quality, case and disease management, credentialing activities and utilization management

- Excellent communication and collaboration skills for work with network providers and internal employees

- Ability to effectively express ideas and gain their acceptance

- Ability to implement new and improved approaches to improvement of care and service quality, and to Care Management activities performed by CareOregon

- Ability to implement clinical and wellness programs to address the needs of high-risk members

- Ability to work effectively as part of a cross-functio