Associate Medical Director

🕒 March 26

🧀 Wisconsin – Remote

🧀 Wisconsin – Remote

⏰ Full Time

🔴 Lead

👨‍⚕️ Medical Director

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Network Health WI

WebsiteLinkedInAll Job Openings

201 - 500 employees

Founded 1982

⚕️ Healthcare Insurance

👥 B2C

Healthcare Insurance • Insurance • B2C

Network Health WI is a health insurance provider based in Wisconsin, offering a range of coverage options including Medicare Advantage, individual and family plans, and employer group health plans. With over 41 years of experience, Network Health is dedicated to building strong and healthy communities by providing accessible healthcare solutions tailored to the needs of its members. The company prides itself on its local presence and commitment to serving the people of Wisconsin, ensuring quality and trustworthy health coverage.

📋 Description

• Assist the CMO with monitoring availability, appropriateness, and necessity of care rendered by participating providers and by out-of-plan providers • Participate in oversight and clinical decision making of the UM program, including but not limited to rendering denial determinations for services not considered medically necessary or experimental/investigation/unproven in accordance with regulatory and quality standards • Contribute to the development of quality care guidelines, internal peer review procedures, and the evaluation of medical care evaluation studies under the NHP quality assurance programs • In coordination with the CMO and Directors of Health Management and QI and Disease Management, share responsibility for the development and continued evaluation of utilization review and quality assessment processes • Provide medical consultation as requested for: • Medical/legal issues • Member grievance procedures • Development and implementation of new benefit packages and the interpretation of covered benefits in NHP contracts • Medical issues related to contract negotiations with health care providers • Determining if services to members/enrollees meet medical criteria • Promote positive relationship between NHP and medical community • Serve as liaison between NHP and providers regarding matters of medical policy and medical administration • Serve as spokesperson for NHP in the medical community and maintains appropriate contact with professional health care organizations • Participate in the ongoing recruitment of plan physicians. • Respond to physicians and other provider inquiries and complaints within established guidelines of the Executive Committee and Board of Directors • Assist in the development of appropriate medical guidelines and parameters for claims review • Assist in the training of NHP staff on matters relating to medical guidelines • Oversight responsibility for monitoring and evaluating Medicare Special Needs Plan Model of Care effectiveness • Perform second level review of provider appeals and disputes • Serve on committees as coordinated with the CMO • Assist in strategic planning targeted towards plan growth initiatives

🎯 Requirements

• Doctor of Medicine (MD or DO), licensed in the state of Wisconsin without restriction • Member in good standing of the local medical community • Must possess a thorough knowledge of the health professional and facilities and standards of practice of medicine in NHP’s service area • Must possess sufficient medical experience and other experience, including knowledge of the Medicare program, to review organization determinations involving medical necessity • Board certified in an ABMS medical specialty required

🏖️ Benefits

• Opportunity to work hard and have fun while getting paid to volunteer in your local neighborhood • Work from home (reliable internet required) • Occasional travel required