Responsibilities Include:
Provide clinical leadership for the utilization management process, including authorizations, denials and appeals. Offer clinical guidance to the Utilization Management nurses and other staff.
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 management 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.
Monitor compliance with physician credentialing and re-credentialing policies and procedures. Review "clean" files and prepare exception report prior to Credentialing Committee meeting.
May serve as the chairperson for the Credentialing Committee and other QI Committees, as delegated by the Chief Medical Officer.
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.
Oversee staff training and education in matters relating to the delivery of medical care, the assurance of quality, and effective control of utilization.
Work with the Chief Medical Officer to assure quality of care in all aspects of medical utilization and to assure that health care utilization is appropriate to meet the needs of the members and falls within the recognized standards of efficiency.
Collaborate with health plan Directors to assure health plan compliance with all regulatory programs including National Committee for Quality Assurance (NCQA), Utilization Review Accreditation Committee (URAC) or general accreditation and State Medicaid guidelines.
Represent the health plan in the medical community, upon request.
Current unrestricted license as Doctor of Medicine or Osteopathy for Illinois is required. Current board certification in his or her designated specialty is required. 3 to 5 years experience in managed care and medical management of health plans or in medical programs administration is required. 5 years Post Graduate experience in direct patient care. Strong experience in developing and/or implementing practice guidelines is required. Experience in providing care to a Medicaid population is preferred. Strong knowledge of utilization management and quality improvement. Working knowledge of the accreditation standards of URAC and the National Committee for Quality Assurance (NCQA) and the Healthcare Effectiveness Data and Information Set (HEDIS).
**This position will be required to train in Detroit, MI for 3-6 months prior to formally taking residence in Illinois. Compensation for lodging will be discussed upon scheduling an interview.
Position Reports To: Chief Medical Officer
Please direct all inquiries to David Mara at (804) 402-8088 or e-mail at dmara@nexushc.com. For more information about Nexus Healthcare go to www.nexushc.com
