Job description
In support of the CMO, the Associate Medical Director is responsible for the administration of procedures, protocols, and standards regarding the efficiency and quality of the health care delivered to Network Health (NH) members. This individual will be chair of at least 3 committees related to quality and accreditation.
Location: Candidates must reside in the state of Wisconsin for consideration. This position is eligible to work at your home office (reliable internet is required). Travel is required occasionally for the position.
Hours: 1.0 FTE, 40 hours per week, 8am - 5pm Monday through Friday, weekend coverage required on rotational basis
Check out our 2025 Community Report to learn a little more about the difference our employees make in the communities we live and work in. As an employee, you will have the opportunity to work hard and have fun while getting paid to volunteer in your local neighborhood. You too, can be part of the team and making a difference. Apply to this position to learn more about our team.
Job Responsibilities:
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 but not limited to 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. In coordination with the CMO and Directors of Health Management and QI and Disease Management, share responsibility for the development and continued evaluation of utilization review and quality assessment processes
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
Determining if services to members/enrollees meet medical criteria
Promote positive relationship between NHP and medical community
Serve as liaison between NHP and providers regarding matters of medical policy and medical administration
Serve as spokesperson for NHP in the medical community and maintains appropriate contact with professional health care organizations
Participates in the ongoing recruitment of plan physicians.
Respond to physicians and other provider inquiries and complaints within established guidelines of the Executive Committee and Board of Directors
Assist in the development of appropriate medical guidelines and parameters for claims review
Assist in the training of NHP staff on matters relating to medical guidelines
Oversight responsibility for monitoring and evaluating Medicare Special Needs Plan Model of Care effectiveness
Perform second level review of provider appeals and disputes
Serve on committees as coordinated with the CMO
Assist in strategic planning targeted towards plan growth initiatives
Job 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
Network Health is an Equal Opportunity Employer
Originally posted on Himalayas
Who can apply
Eligible countries: United States. Accepted UTC offsets: UTC-10, UTC-9, UTC-8, UTC-7, UTC-6, UTC-5, UTC+14. Review the full description for employer-specific work authorization, residency and schedule requirements.