Lancesoft INC
The Associate Medical Director will take a hands-on approach in overseeing and supporting clinical activities, ensuring the delivery of comprehensive care to members.
This is a 13-week locum assignment with the intention of transitioning the provider into a permanent role.
Responsibilities:
This is a 13-week locum assignment with the intention of transitioning the provider into a permanent role.
Responsibilities:
- Reviews prior authorization and appeals requests for approval or denial of claims payment based on medical necessity.
- Performs peer-to-peer calls as necessary to support the utilization management process.
- Provides clinical oversight for utilization management, disease management, and quality management activities as assigned by leadership, including participation in development of medical policies and procedures for coverage, authorization, and clinical standards based on evidence-based medicine.
- Analyzes data to establish health care provider profiles and define acceptability of physician performance; conducts review of provider applications and qualifications; participates in the review process for providers who fail to meet required standards; and conducts site and medical record reviews, as appropriate, to ensure adherence to managed care policies.
- Assists leadership and the Pharmacy Director in overseeing and administering the pharmacy benefit, including coordination of care between the medical and pharmacy benefits.
- Assists leadership in oversight, evaluation, and administration of the clinical aspects of fraud, waste, and abuse programs.
- Participates in development, implementation, and monitoring of annual goals and objectives that support the mission and objectives of the organization.
- Assists in identifying member and provider needs for education and health promotion; participates in assessment, development, and evaluation of educational programs to ensure they meet managed care service needs.
- As assigned, assists in representing the organization on clinical activities with relevant state and local bodies such as regulatory and professional agencies.
- Participates in identification and analysis of process improvements in job design, work processes, and workflows, and implements appropriate changes to improve effectiveness, productivity, and efficiency in support of managed care goals.
- As assigned, serves as chairperson or member of managed care committees and participates on various community and interdisciplinary committees.