Medical Director

• Supports operations in the form of case review on both medical and regulatory matters.
• Develops claim adjudication criteria for situations requiring medical judgment.
• Provides input on issues and operational policies, processes, and procedures.
• Educates staff and medical community on various aspects of medical policy and program administration.
• May develop and update medical policy in consultation with appropriate regulatory personnel, medical consultants, and professional societies.
• Develops external relationships with the medical community and serves as liaison between these entities and the contractors.
• Reviews physician and provider practice pattern analysis and other statistical data related to unusual medical service utilization.
• Conducts research into new or controversial medical procedures and technology.

Chief Medical Officer – Medicare Policy

• Provides administrative oversight to the medical staff
• Analyzes medical review utilization data
• Researches new medical procedures or technology
• Acts as a lead resource to providers and internal staff on issues concerning medical policies
• Heavily involved in policy generation, includes the development of new policy and revision of old policy
• Supports operations in the form of case review on both medical and regulatory matters
• Develops claim adjudication criteria for situations requiring medical judgment
• Educates staff and medical community on various aspects of medical policy and program administration
• Develops and updates medical policy in consultation with regulatory personnel, medical consultants, and professional societies
• Develops external relationships with the medical community and serves as liaison between these entities and the contractors
• Reviews physician and provider practice pattern analysis and other statistical data related to unusual medical service utilization
• Conducts research into new or controversial medical procedures and technology

• Market Physician Executive (MPE) are mission driven physician leaders who are dedicated to improving the well-being, quality of life, and health outcomes for our patients
• The MPE will lead our in-home multi-specialty polychronic care model in an assigned market
• Each market is comprised of 5-10 practices led by local advanced practice providers (APP), registered nurses(RN), licensed clinical social workers (LCSW), and pharmacists (PharmD)
• The MPE will collaborate with Monogram Health’s Multi-Specialty Platform to leverage employed specialists to deliver in-home specialty care
• Monogram Health deploys a proven risk-based model to ensure health equity and health equality leveraging proprietary next generation AI algorithms to predict the appropriate level of care
• Aligning with the quadruple AIM, the MPE will focus to improve patient experience, population health outcomes, provider satisfaction and lower costs
• The primary goal of each MPE to deliver exceptional outcomes through disease detection and evidence based clinical pathways and disease treatment
• Reporting to the Region President, the Market Physician Executive (MPE) is a key clinical leader within Monogram Health who contributes to the development and oversight of clinical strategies, policies, programs, processes, protocols, guidelines, and operations that drive improved patient health outcomes within the market
• The MPE oversees the daily clinical and business operations through delivery of direct patient care, care management services, social worker support and pharmacy services within the market
• In support of the advance practice providers the MPE is expected to review and approve care plans and direct the treatment plans for our patients
• The MPE will collaborate with community physicians, facilities, and partners in peer to peer and direct patient care decision making
• Overall accountability for reducing total cost of care and Medical Loss Ratio
• Responsible for clinical outcomes to include, but not limited to, clinical interventions closure, inpatient/outpatient utilization, pharmacological prescribing and therapy management, multi-specialty platform and HEDIS/Gap Closure
• Actively lead daily high risk and concurrent review rounds
• Direct supervision of front line clinical and operations team members
• Oversee and delegate operational responsibility to Market Manager
• Regularly assess and present market performance and outcomes to Executive and Senior Leaders

Market Physician Executive – Float

• Determines the medical necessity of requests using clinical criteria
• Performs physician-level case review of surgical utilization requests
• Conducts peer-to-peer consultation with ordering physicians, physician assistants and advanced practice nurses regarding established guidelines and accepted standards of care as it relates to treatments, procedures, imaging and appropriate sites of service
• Provides education regarding applicable clinical criteria and discusses clinically appropriate interventional and non-interventional options
• Performs first level provider appeals for coverage decisions
• Provides support and education to internal clinical and non-clinical staff regarding the principles associated with appropriate diagnoses, treatments, and management of conditions and surgical procedures
• Participates in physician team meetings
• Participates in groups that develop, revise and enhance clinical appropriateness guidelines

Medical Director – Surgery

• Monogram Market Physician Executive (MPE) are mission driven physician leaders who are dedicated to improving the well-being, quality of life, and health outcomes for our patients
• The MPE will lead our in-home multi-specialty polychronic care model in an assigned market
• The MPE will collaborate with Monogram Health’s Multi-Specialty Platform to leverage employed specialists to deliver in-home specialty care
• Aligning with the quadruple AIM, the MPE will focus to improve patient experience, population health outcomes, provider satisfaction and lower costs
• The primary goal of each MPE to deliver exceptional outcomes through disease detection and evidence based clinical pathways and disease treatment
• Reporting to the Region President, the Market Physician Executive (MPE) is a key clinical leader within Monogram Health who contributes to the development and oversight of clinical strategies, policies, programs, processes, protocols, guidelines, and operations that drive improved patient health outcomes within the market
• The MPE oversees the daily clinical and business operations through delivery of direct patient care, care management services, social worker support and pharmacy services within the market

Market Physician Executive

• Develop and manage the Clinical Policy, Regulatory, and Compliance functions within the Office of Clinical Affairs.
• Ensure clinical operations meet healthcare laws and standards.
• Develop and maintain regulatory policies.
• Manage compliance risks and guide policy-related submissions.
• Advise senior leadership and work closely with teams across the organization.

Medical Director, Clinical Regulatory Affairs

• Assure that patient’s medical history and physical examination is completed within twenty-four (24) hours of campus admission
• Supervision of staff medical personnel, as designated
• Routine medical visits and treatment as requested or as indicated
• Formulation of standing orders in conjunction with Corporate Medical Director
• Assure that patients are referred to proper agencies when treatment is beyond our scope
• Provide admission, transfer and discharge orders
• Participate in utilization review
• Attend and participate in clinical staffing
• Facility leadership with regards to new findings in the field of addictions treatment
• Assure twenty-four (24) hour, seven (7) day weekly medical coverage
• Must be able to work in a cooperative manner with co-workers, managers, clients and prospective clients
• Must be able to work in constant state of alertness as to perform the job in a safe manner

• Determines the medical necessity of requests using clinical criteria
• Performs physician-level case review of oncologic utilization requests
• Conducts peer-to-peer consultation with ordering physicians, physician assistants and advanced practice nurses regarding established guidelines and accepted standards of care as it relates to treatments, procedures, imaging and appropriate sites of service
• Provides education regarding applicable clinical criteria and discusses clinically appropriate options
• Performs first level provider appeals for coverage decisions
• Provides support and education to internal clinical and non-clinical staff regarding the principles associated with appropriate diagnoses, treatments, and management related to these specialties
• Participates in physician team meetings
• Participates in groups that develop, revise and enhance clinical appropriateness guidelines

Medical Director – Genetic Testing, Oncology

• Provide medical consultation in transfusion medicine, blood banking, and patient services to hospital clients, fostering strong and collaborative relationships.
• Deliver continuing medical education to internal and external audiences, promoting safe and effective use of blood components.
• Lead patient service programs such as therapeutic apheresis, stem cell collection and processing, perioperative autologous cell salvage, and patient blood management.
• Oversee medical aspects of regulated blood center operations including donor management, recipient adverse reactions, and product investigations.
• Contribute to the development of policies and procedures related to donor eligibility, component quality, and transfusion practices.
• Serve as CLIA Laboratory Director for regulated collection activities and laboratories including immunohematology, HLA, stem cell, and national testing labs.
• Investigate donor and recipient concerns, transfusion-related issues, and customer service complaints, ensuring timely resolution and appropriate leadership notification.
• Support, mentor, and guide volunteers to enhance their contributions and professional development.

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Chief Medical Officer – Medicare Policy

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