Presbyterian Healthcare Services
Health Plan Medical Director (MD/DO)
Presbyterian Healthcare Services, Albuquerque, New Mexico, United States, 87101
Overview
Presbyterian Healthcare Services exists to improve the health of patients, members, and the communities we serve. We are a locally owned, not-for-profit healthcare system comprising nine hospitals, a statewide health plan, and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees, including over 1,600 providers and nearly 4,700 nurses. Our health plan serves more than 580,000 members statewide, offering Medicare Advantage, Medicaid (Centennial Care), and Commercial health plans. The Presbyterian Health Plan (PHP)
Medical Director
reports to PHP's Senior Medical Director. The role involves primarily performing
medical necessity determinations
in collaboration with PHP's Utilization Management team, ensuring adherence to medical protocols and practice guidelines. This includes managing healthcare service utilization, especially through prior authorization, participating in complex
care coordination , and engaging in peer-to-peer discussions with community clinicians. The
Medical Director
will provide medical oversight, expertise, and leadership to ensure the delivery of cost-effective, high-quality healthcare services to PHP members. This position is primarily based in New Mexico; remote candidates in other states may be considered. Remote employees cannot reside in California, Washington, Illinois, North Dakota, Ohio, or New York. Responsibilities
The position offers opportunities for professional, cultural, and personal growth, including: Supporting development and updates to Medical Policies Assisting initiatives to improve access to quality, affordable care for PHP members Providing clinical leadership and promoting best practices across Presbyterian Managing relationships with providers statewide Supporting population health, especially among vulnerable populations Playing a key role within an integrated healthcare system Innovating in medical cost and population health management Contributing to the improvement of health outcomes in New Mexico Guiding quality improvement initiatives Performing other duties as required Position Requirements
M.D. or D.O. with board certification At least five years of clinical practice in pediatric and adult medicine post-residency, with a valid New Mexico license Managed care experience preferred Experience with clinical practice guidelines, resource utilization, and cost management Proficiency with Microsoft Office and electronic medical records In-depth knowledge of medical management principles, including utilization and case management, reviews, and prior authorization Understanding of managed care environments Experience with Medicare, Medicaid, and state programs is desirable Familiarity with NCQA and HEDIS principles is a plus Benefits
We offer more than standard benefits! Our wellness program includes free access to gyms, nutrition coaching, wellness challenges, and more. Learn more:
https://www.phs.org/careers/why-work-with-us/benefits Why Work at Presbyterian?
We are dedicated to community health improvement through initiatives like farmers' markets and local partnerships. Our employees' dedication has helped grow Presbyterian from a small sanatorium to a statewide healthcare system serving over 875,000 New Mexicans. About New Mexico
New Mexico offers a growing population, low cost of living, diverse landscapes, and numerous recreational activities, making it an ideal place for active lifestyles and exploration. AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke-free campuses.
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Presbyterian Healthcare Services exists to improve the health of patients, members, and the communities we serve. We are a locally owned, not-for-profit healthcare system comprising nine hospitals, a statewide health plan, and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees, including over 1,600 providers and nearly 4,700 nurses. Our health plan serves more than 580,000 members statewide, offering Medicare Advantage, Medicaid (Centennial Care), and Commercial health plans. The Presbyterian Health Plan (PHP)
Medical Director
reports to PHP's Senior Medical Director. The role involves primarily performing
medical necessity determinations
in collaboration with PHP's Utilization Management team, ensuring adherence to medical protocols and practice guidelines. This includes managing healthcare service utilization, especially through prior authorization, participating in complex
care coordination , and engaging in peer-to-peer discussions with community clinicians. The
Medical Director
will provide medical oversight, expertise, and leadership to ensure the delivery of cost-effective, high-quality healthcare services to PHP members. This position is primarily based in New Mexico; remote candidates in other states may be considered. Remote employees cannot reside in California, Washington, Illinois, North Dakota, Ohio, or New York. Responsibilities
The position offers opportunities for professional, cultural, and personal growth, including: Supporting development and updates to Medical Policies Assisting initiatives to improve access to quality, affordable care for PHP members Providing clinical leadership and promoting best practices across Presbyterian Managing relationships with providers statewide Supporting population health, especially among vulnerable populations Playing a key role within an integrated healthcare system Innovating in medical cost and population health management Contributing to the improvement of health outcomes in New Mexico Guiding quality improvement initiatives Performing other duties as required Position Requirements
M.D. or D.O. with board certification At least five years of clinical practice in pediatric and adult medicine post-residency, with a valid New Mexico license Managed care experience preferred Experience with clinical practice guidelines, resource utilization, and cost management Proficiency with Microsoft Office and electronic medical records In-depth knowledge of medical management principles, including utilization and case management, reviews, and prior authorization Understanding of managed care environments Experience with Medicare, Medicaid, and state programs is desirable Familiarity with NCQA and HEDIS principles is a plus Benefits
We offer more than standard benefits! Our wellness program includes free access to gyms, nutrition coaching, wellness challenges, and more. Learn more:
https://www.phs.org/careers/why-work-with-us/benefits Why Work at Presbyterian?
We are dedicated to community health improvement through initiatives like farmers' markets and local partnerships. Our employees' dedication has helped grow Presbyterian from a small sanatorium to a statewide healthcare system serving over 875,000 New Mexicans. About New Mexico
New Mexico offers a growing population, low cost of living, diverse landscapes, and numerous recreational activities, making it an ideal place for active lifestyles and exploration. AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke-free campuses.
#J-18808-Ljbffr