Associate Medical Director
Network Health WI
full-time
Posted on:
Location Type: Hybrid
Location: Menasha • Wisconsin • United States
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Job Level
About the role
- Responsible for the administration of procedures, protocols, and standards regarding the efficiency and quality of the health care delivered to Network Health (NH) members
- Chair of at least 3 committees related to quality and accreditation
- 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 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
- 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
- Promote a positive relationship between NHP and the medical community
- Serve as liaison between NHP and providers regarding matters of medical policy and medical administration
- Perform second level review of provider appeals and disputes
- 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
- An active practitioner of medicine in the NHP service areas
- 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
- reliable internet is required
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
medical consultationquality assuranceclinical decision makingmedical necessity reviewpeer review proceduresdenial determinationshealth care protocolsquality care guidelinescontract negotiationsstrategic planning
Soft Skills
leadershipcommunicationinterpersonal skillscollaborationproblem-solvingrelationship managementorganizational skillsnegotiationconflict resolutionadvisory skills
Certifications
Doctor of Medicine (MD or DO)board certification in ABMS medical specialty