Medical Director - Denver Health Medical Plan •must Reside I

Medical Director - Denver Health Medical Plan

We are recruiting for a motivated Medical Director to join our team! The Medical Director of Managed Care functions as the Denver Health Medical Plan's Chief Medical Officer and is responsible for the development, implementation, and evaluation of medical management activities carried out by Managed Care on behalf of its members. The overarching goals of these activities are to fulfill regulatory requirements, improve member care and outcomes, reduce unnecessary health care expenses, and insure that clinical services are provided in a manner consistent with each health plan's b Essential Functions :

• Supports relevant functions of the Pharmacy and Quality Improvement & Accreditation Departments and utilization, care, and disease management processes.
• Serves as a liaison to the clinical departments at Denver Health. Responsible for educating Denver Health's clinical providers about the Medical Plan's benefit plans and management resources.
• Supports Managed Care's medical management initiatives with the clinical activities in Denver Health's inpatient and outpatient settings.
• The Medical Director may serve on various Denver Health Committees.
• Provides clinical oversight and support for the Medical Management areas of : Pharmacy, Quality Management and UM / CM / DM.
• Engages with Denver Health and external providers to address practice patterns to ensure member care and quality initiatives.
• For each line of business in the Medical Plan, develops and monitors annual cost and utilization targets for key medical service areas such as : pharmacy, admissions, LOS, re-admissions, ED utilization.
• Evaluates utilization, national and local trends and identifies interventions to optimize the utilization of resources, control cost and delivery of quality health care services.
• Monitors medical costs outside of Denver Health. Identify areas of opportunities to bring more services into Denver Health.
• Provides clinical direction to the Quality Management, Pharmacy and Medical Management Departments in the development of clinical initiatives and programs for the annual Quality Improvement Work Plan by line of business.
• Responsible for supporting the Quality Improvement Program for Denver Health Medical Plan and Denver Health Medicaid Choice.
• Responsible for analyzing HEDIS results for all lines of business and reviewing Quality Improvement measures and others areas to identify clinical measures for planned interventions.
• Oversees the process of reviewing quality of care concerns and remediating identified quality of care problems.
• Remains abreast of applicable contractual and regulatory quality clinical requirements for Medicaid / CHP, Medicare, Commercial and Exchange lines of business.
• Works with the Quality Management, Pharmacy and Medical Management Departments on the implementation of processes, policies and programs to meet all requirements.
• Ensures that all contractual, regulatory and accreditation requirements are met by Medical Management functional areas. Participate in on-site audits.
• Represents the Plan in external regulatory audits, HEDIS audits, and accreditation site reviews for medical management.
• Meets as needed with applicable regulatory agencies and contractors to clarify requirements, resolve issues, develop, and collaborate on programs to meet uch requirements.
• Promotes the development of innovative programs that meet members' healthcare needs, promote disease management, and improve behavioral health and wellness.
• Develops and implements plans to improve employee engagement in collaboration with department directors and their managers.

Education : Doctorate Degree required Work Experience : 10+ years Clinical practice experience required and Three years of managed care experience (either in a medical group or health plan) in utilization management, population health, disease management, health care quality improvement programs, or clinical guideline development and implementation required or Three years managerial experience required Licenses : MD-Physician - State Medical Board required Knowledge, Skills and Abilities : Demonstrates an understanding of quality improvement, population health, disease management, utilization, case and disease management programs and healthcare financing and costs. Ability to develop collaborative relationships with internal departments and providers at Denver Health as well as all external providers and partners. Must have effective oral and written... For full info follow application link. Denver Health is committed to provide equal treatment and equal employment opportunities to all applicants and employees. Denver Health is an Equal Opportunity Employer and does not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.