MEDICAL DIRECTOR 18673 ND

WellPoint is the nation's leading health benefits company serving the needs of approximately 28 million medical members nationwide.



The Medical Director is responsible for prospective and retrospective clinical case review and determination of medical necessity. The individual is responsible with others in developing, implementing and monitoring clinical protocols, utilization review clinical program design, and physician/facility intervention programs when appropriate.  The individual, under the direction of the Regional Vice President, Medical Director, supports daily clinical operations including but not limited to case reviews, utilization management physician/facility communications and assessing/monitoring medical management program performance.  He/she may provide guidance to associate medical directors as requested by the RVP on an ad hoc basis. 

 

This position reports to the Regional Vice President, Regional Medical Director.  The individual will have regular contact with UM clinical and non clinical staff, medical policy and quality improvement staff; and external network physicians and facility representatives.

 

The Medical Director will be responsible for:Performing case reviews on all referred casesProviding support and on going medical education and guidance for the clinical staff, including associate medical directors, as requestedAssuring compliance of corporate medical and UM administrative policiesAssuring compliance with accepted quality of care standardsProviding consultative assistance to staff internal and external to UM, as appropriateEstablishing and maintaining effective relations with physicians and hospitals

Providing guidance to physicians in explaining policies and procedures and developing and supporting implementation of provider/facility interventions when care is inappropriate, unnecessary, or not consistent with established standards.

 Perform all medical review activities as requested, including but not limited to prospective, retrospective and appeals cases and issue medical necessity denial determinations when indicated Develop and implement with others provider/facility interventions when care is identified as inappropriate, unnecessary, or not consistent with established standardsMaintain corporate medical policy for UM to ensure consistencyDevelop and maintain effective relationships with physicians and facilities and achieve credibility as a utilization management medical director Participate in the UM program development and assessment of its performance with the UM management and staffProvide consultative support when requested and appropriate to other areas of the company

Board Certified physician, preferably in a primary care specialty; Hold an active New York State, Connecticut, Maine or New Hampshire medical license Have at least five years of active clinical experience.  Excellent communication skills and interpersonal skills requiredAt least 5-7 years of  utilization management experience required.