GENERAL SUMMARY
Oversees the medical management programs for assigned business sector. Provides medical leadership to ensure excellent quality of care and service is provided to our members/clients that is efficient and cost effective.
ESSENTIAL RESPONSIBILITIES
- Provides technical expertise in medical management by direct decision making in the areas of preauthorization, concurrent review of hospitalized patients, discharge planning, complex case and chronic care management, and credentialing.
- Oversees the clinical aspects of the quality management, credentialing, pharmacy, and medical management program.
- Chairs (or staffs) all peer-review committees such as Quality Improvement, Pharmacy and Therapeutics, Credentialing, and others that are deemed appropriate for the health plan. May participate in the Physicians Advisory Committee. Takes part in periodic consultations and/or conversations with peers and practitioners in the field.
- Analyzes medical cost drivers and develops specific plans to reduce excessive cost.
- Works with senior leadership to develop strategic approaches to improve company performance and expand growth by optimizing provider network, evaluating provider (hospital, physician, ancillary) contracts, and developing other creative approaches.
- Provides oversight for all quality improvement projects.
- Provides oversight for all accreditation activities (URAC and/or NCQA) within the assigned business sector.
- For Medical Directors with senior clinical staff responsibilities, ensures a staff of qualified clinicians accountable to the organization for decisions affecting consumers is maintained, and that appeals are reviewed by non-subordinate board certified specialists.
- Recruits, develops, and motivates staff. Initiates and communicates a variety of personnel actions including employment, termination, performance reviews, salary reviews, and disciplinary actions.
- Performs other duties as required.
Qualifications:
Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Executive/Senior Level Officials and Managers
Primary Location: Richmond, VA, US
Other Locations: Charlottesville-Virginia-United States,
Organization: 25400 - Coventry Health Care of Virginia, Inc.
Schedule: Full-time
Job Posting: 2013-01-03 00:00:00.0
Job ID: 1310019