Martin's Point Health Care
Medical Director - Health Plan
Martin's Point Health Care, Portland, Maine, us, 04122
Martin's Point Health Care - Medical Director - Health Plan
Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.Position SummaryThe Health Plan Medical Director provides leadership for the clinical care systems that improve the health of our health plan population under the guidance of the Institute for Health Improvement Triple Aim.Key Outcomes:Participates in clinical aspects of utilization management decision-making, including the establishment of quality standards and performance audits for clinical staff to ensure consistent and accurate decisions.Supports the selection, development and maintenance of medical policies and clinical protocols that support utilization management, care management and chronic care management operations.Contracts and coordinates the services of independent review organizations and individual physicians to satisfy peer reviews for utilization management and appeals decisions.Collaborates with leadership team on the effective medical cost and utilization performance of the health plan and assists with the development and deployment of strategies for effective medical cost and quality of care management.Partners with community providers and the medical leadership of network groups to create support for Martin’s Point utilization and population health initiatives.Provides clinical input and guidance for Health Plan Quality Committees (e.g., credentialing, Physician Advisory Group, and delegation oversight).Ensures all clinical programs comply with government program regulations and NCQA accreditation requirements.Provides clinical expertise to support product and benefit development efforts.Manages the clinical aspects of member and provider appeal processing and decision-making.Education/ExperienceMedical degree with 10+ years of practice experience required, including applicable managed care experience with progressively increasing responsibilities in medical director capacities, including utilization management and medical policy development, required.Leadership experience preferred.Knowledge of local provider community (preferred).Required License(s) and/or Certification(s):Active and unrestricted license to practice medicine in Maine or NH required.ABMS Board Certification.Extensive knowledge and practical understanding of healthcare systems and managed care concepts.Demonstrated ability to develop medical policy and manage cost of care under the guidance of the Triple Aim.Demonstrated ability to lead, manage and collaborate with others, even without authority.Demonstrated ability to educate and promote best practices to physician and clinical care communities.Good analytic skills with the ability to identify meaningful trends and targets for improvement.Excellent interpersonal skills and the demonstrated ability to establish rapport and working relationships with providers, service vendors, employers, regulatory and community groups.Strong communication and presentation skills; ability to tailor message to a variety of audiences.Successful utilization of process improvement tools and methods to achieve results.We are an equal opportunity/affirmative action employer.For questions about careers at Martin’s Point Health Care, contact us at: jobinquiries@martinspoint.org
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Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.Position SummaryThe Health Plan Medical Director provides leadership for the clinical care systems that improve the health of our health plan population under the guidance of the Institute for Health Improvement Triple Aim.Key Outcomes:Participates in clinical aspects of utilization management decision-making, including the establishment of quality standards and performance audits for clinical staff to ensure consistent and accurate decisions.Supports the selection, development and maintenance of medical policies and clinical protocols that support utilization management, care management and chronic care management operations.Contracts and coordinates the services of independent review organizations and individual physicians to satisfy peer reviews for utilization management and appeals decisions.Collaborates with leadership team on the effective medical cost and utilization performance of the health plan and assists with the development and deployment of strategies for effective medical cost and quality of care management.Partners with community providers and the medical leadership of network groups to create support for Martin’s Point utilization and population health initiatives.Provides clinical input and guidance for Health Plan Quality Committees (e.g., credentialing, Physician Advisory Group, and delegation oversight).Ensures all clinical programs comply with government program regulations and NCQA accreditation requirements.Provides clinical expertise to support product and benefit development efforts.Manages the clinical aspects of member and provider appeal processing and decision-making.Education/ExperienceMedical degree with 10+ years of practice experience required, including applicable managed care experience with progressively increasing responsibilities in medical director capacities, including utilization management and medical policy development, required.Leadership experience preferred.Knowledge of local provider community (preferred).Required License(s) and/or Certification(s):Active and unrestricted license to practice medicine in Maine or NH required.ABMS Board Certification.Extensive knowledge and practical understanding of healthcare systems and managed care concepts.Demonstrated ability to develop medical policy and manage cost of care under the guidance of the Triple Aim.Demonstrated ability to lead, manage and collaborate with others, even without authority.Demonstrated ability to educate and promote best practices to physician and clinical care communities.Good analytic skills with the ability to identify meaningful trends and targets for improvement.Excellent interpersonal skills and the demonstrated ability to establish rapport and working relationships with providers, service vendors, employers, regulatory and community groups.Strong communication and presentation skills; ability to tailor message to a variety of audiences.Successful utilization of process improvement tools and methods to achieve results.We are an equal opportunity/affirmative action employer.For questions about careers at Martin’s Point Health Care, contact us at: jobinquiries@martinspoint.org
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