Associate Medical Director

🕒 il y a 6 mois

🧀 Wisconsin – Distant

🧀 Wisconsin – Remote

⏰ Temps Plein

🔴 Expert

👨‍⚕️ Directeur Médical

👻 Score fantôme 53%

Ce que ça veut dire : la probabilité que cette offre reste ouverte sans recrutement actif.Comment le lire : 60 % ou plus, on pense que c'est une offre fantôme. Un score plus bas est moins inquiétant.Comment on la calcule : ancienneté, republications, postes ouverts vs taille de l'équipe, rapidité de clôture, et si le salaire est indiqué.À noter : une estimation à partir de données publiques, pas un jugement sur l'entreprise. De vraies offres peuvent avoir un score élevé, alors prenez-le comme un indice, pas comme un fait.

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Network Health WI

Site WebLinkedInTous les Emplois

201 - 500 employés

Fondée en 1982

🏥 Santé

💼 Conseil

📦 Logistique

Healthcare • Consulting • Logistics

Network Health WI est un fournisseur d'assurance santé basé dans le Wisconsin, proposant une gamme d'options de couverture incluant Medicare Advantage, des plans individuels et familiaux, ainsi que des plans de santé pour les groupes d'employeurs. Fort de plus de 41 ans d'expérience, Network Health s'engage à bâtir des communautés solides et en bonne santé en fournissant des solutions de santé accessibles et adaptées aux besoins de ses membres. La société se targue de sa présence locale et de son engagement à servir les habitants du Wisconsin, en assurant une couverture santé de qualité et fiable.

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

🎯 Exigences

• 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

🏖️ Avantages

• 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