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Job description
Job Title
Associate Medical Director
Position Overview
The Associate Medical Director will actively oversee and support clinical operations, ensuring the provision of comprehensive care within a managed care framework.
Key Responsibilities
Evaluate prior authorization and appeals requests to determine claims payment based on medical necessity.
Conduct peer-to-peer discussions as required to facilitate the utilization management process.
Provide clinical oversight for utilization management, disease management, and quality management initiatives as directed by the Chief Medical Officer (CMO) or Senior Medical Director, including input on the development of medical policies, clinical standards, and guidelines that align with evidence-based medicine.
Analyze healthcare provider data to create provider profiles and assess physician performance; participate in the review of provider applications and qualifications, addressing any discrepancies in adherence to managed care standards through site and medical record reviews.
Collaborate with the Senior Medical Director and Pharmacy Director in the management and administration of pharmacy benefits for PCHP members, ensuring coordinated care between medical and pharmacy services.
Support the Senior Medical Director in overseeing the clinical components of programs addressing fraud, waste, and abuse within PCHP.
Contribute to the formulation, implementation, and monitoring of annual departmental goals and objectives.
Identify educational and health promotion needs for members and providers, assessing and enhancing existing educational initiatives to align with managed care service requirements.
Represent PCHP in clinical matters at state and local organizations, including the Texas Department of Insurance and Texas Health and Human Services Commission, as directed by the CMO or Senior Medical Director.
Engage in process improvement initiatives concerning job design and workflows, implementing changes to boost operational effectiveness and efficiency within the clinical setting.
Serve on managed care committees and participate in community and interdisciplinary committees as assigned by the Chief Medical Officer or Senior Medical Director.
Accountabilities
Analyze job design and workflows to implement strategies that enhance departmental effectiveness, productivity, and efficiency.
Stay current with developments in the field through seminars, workshops, professional journals, and participation in relevant organizations, integrating new knowledge into practice.
Maintain up-to-date understanding of laws, regulations, and guidelines affecting the area and develop internal controls to ensure compliance with applicable laws and accreditation standards.
Construct and manage annual budgets to ensure adequate funding for departmental objectives.
Develop and revise annual goals and objectives that align with organizational missions; supervise and evaluate staff, providing training and development opportunities while facilitating disciplinary actions as necessary.
Required Skills and Qualifications
Strong alignment with the managed care philosophy of healthcare delivery.
Robust knowledge of managed care principles.
Exemplary leadership, organizational, and interpersonal communication skills, with the ability to engage effectively with executive management, physician groups, community organizations, and diverse populations.
Proficient understanding of Texas Medicaid Regulations and their applications.
Licensure and Experience
Board certification in OB/GYN or a relevant specialty is mandatory (no exceptions).
A valid Texas medical license (or a willingness to obtain) is required.
A clean malpractice/license history is highly preferred.
Experience in managed care and prior authorization is essential.
Participation in a managed care utilization management committee is preferred.
Capacity to adapt to the managed care delivery model is crucial.
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Worksite address
dallas, TX, 75215, US
Who can apply
Review the original listing for work authorization, qualifications and employer requirements.