Medical Director

• Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit
• Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities
• Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services
• Supports effective implementation of performance improvement initiatives for capitated providers
• Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals
• Assists in the development and implementation of physician education with respect to clinical issues and policies
• Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment
• Represents the business unit at appropriate state committees and other ad hoc committees.

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