Presbyterian Healthcare Services
Health Plan Medical Director (MD/DO)
Presbyterian Healthcare Services, Albuquerque, New Mexico, United States, 87101
Overview
Health Plan Medical Director (MD/DO) role at Presbyterian Healthcare Services. The Medical Director reports to PHP's Senior Medical Director and will be responsible for medical necessity determinations in partnership with PHP’s Utilization Management, ensuring medical protocols and practice guidelines are followed. The position includes utilization management of health care services, participation in formulating complex care coordination, and peer-to-peer discussions with community clinicians. The Medical Director will provide medical oversight, expertise, and leadership to ensure the delivery of cost-effective, quality healthcare services for PHP members. This role is intended to be conducted within New Mexico; remote candidates in other states may be considered. Remote employees may not reside in California, Washington, Illinois, North Dakota, Ohio or New York. Interested in learning more? Text 505.388.0350 or schedule directly with the recruiter. Qualifications
M.D. or D.O. with board certification. Five years of clinical practice experience in pediatric and adult medicine after residency training; currently NM licensed to practice without restriction. Experience in a managed care setting strongly preferred. Experience applying evidence-based clinical practice guidelines and resource, utilization, and cost management initiatives. Basic computer literacy (e.g., Microsoft Office, electronic medical records). Detailed knowledge of medical management principles, including utilization management, case management, retrospective and concurrent review, and prior authorization; capable of serving as a resource or educator to other practitioners. Understanding of the managed care environment. Experience with Medicare, Medicaid and state programs desirable. Familiarity with NCQA and HEDIS principles and requirements desirable. Responsibilities
Support development and revisions to Medical Policies. Assist in initiatives to ensure accessibility of quality, affordable care and coverage for PHP customers and members. Provide clinical leadership and promote best practices across the Presbyterian organization. Manage relationships with providers across the state. Support population health efforts, including a large population of vulnerable individuals, in achieving their best health. Play an integral role within a fully integrated healthcare system. Break new ground in medical cost management and population health management. Support New Mexico in improving the health of its population. Provide guidance and support for forward-thinking quality improvement initiatives. Other functions as required. Benefits
Presbyterian employees gain access to a robust wellness program, including free access to on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more. Learn more about our employee benefits at: https://www.phs.org/careers/why-work-with-us/benefits AA/EOE/VET/DISABLED. Presbyterian is a drug-free and tobacco-free employer with smoke-free campuses. Offer Details
Maximum offer for this position is up to USD $136.00/hour. The compensation range takes into account experience and training, internal equity, and other business needs. Additional Information
Seniority level: Mid-Senior level Employment type: Full-time Job function: Health Care Provider Industries: Hospitals and Health Care
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Health Plan Medical Director (MD/DO) role at Presbyterian Healthcare Services. The Medical Director reports to PHP's Senior Medical Director and will be responsible for medical necessity determinations in partnership with PHP’s Utilization Management, ensuring medical protocols and practice guidelines are followed. The position includes utilization management of health care services, participation in formulating complex care coordination, and peer-to-peer discussions with community clinicians. The Medical Director will provide medical oversight, expertise, and leadership to ensure the delivery of cost-effective, quality healthcare services for PHP members. This role is intended to be conducted within New Mexico; remote candidates in other states may be considered. Remote employees may not reside in California, Washington, Illinois, North Dakota, Ohio or New York. Interested in learning more? Text 505.388.0350 or schedule directly with the recruiter. Qualifications
M.D. or D.O. with board certification. Five years of clinical practice experience in pediatric and adult medicine after residency training; currently NM licensed to practice without restriction. Experience in a managed care setting strongly preferred. Experience applying evidence-based clinical practice guidelines and resource, utilization, and cost management initiatives. Basic computer literacy (e.g., Microsoft Office, electronic medical records). Detailed knowledge of medical management principles, including utilization management, case management, retrospective and concurrent review, and prior authorization; capable of serving as a resource or educator to other practitioners. Understanding of the managed care environment. Experience with Medicare, Medicaid and state programs desirable. Familiarity with NCQA and HEDIS principles and requirements desirable. Responsibilities
Support development and revisions to Medical Policies. Assist in initiatives to ensure accessibility of quality, affordable care and coverage for PHP customers and members. Provide clinical leadership and promote best practices across the Presbyterian organization. Manage relationships with providers across the state. Support population health efforts, including a large population of vulnerable individuals, in achieving their best health. Play an integral role within a fully integrated healthcare system. Break new ground in medical cost management and population health management. Support New Mexico in improving the health of its population. Provide guidance and support for forward-thinking quality improvement initiatives. Other functions as required. Benefits
Presbyterian employees gain access to a robust wellness program, including free access to on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more. Learn more about our employee benefits at: https://www.phs.org/careers/why-work-with-us/benefits AA/EOE/VET/DISABLED. Presbyterian is a drug-free and tobacco-free employer with smoke-free campuses. Offer Details
Maximum offer for this position is up to USD $136.00/hour. The compensation range takes into account experience and training, internal equity, and other business needs. Additional Information
Seniority level: Mid-Senior level Employment type: Full-time Job function: Health Care Provider Industries: Hospitals and Health Care
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