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Job description
About Priority Health
We are the second largest and fastest growing health plan in Michigan focused on improving the health and lives across the state , a nd we couldn't do it without the incredible talent of our employees. It is their commitment that continues to drive our success as a nationally recognized nonprofit health benefits company. As part of the Corewell Health system , our team members have a unique ability to grow and advance their career while maintaining their seniority and benefits.
Scope of Work
The Medical Director role is critical to Priority Health's mission of improving health, inspiring hope and saving lives as we partner with medical communities. Expectations will include: A strong understanding of the guiding principles of; Right care, Right time, Right place, Right cost. This strong understanding of the guiding principles will be demonstrated through applications of evidence-based utilization review process and application of sound clinical judgement. The medical director will be part of the medical director teams and will work jointly with each of the lines of business leaders to assure compliant, evidence-informed decisions are provided. This position will have responsibilities including peer to peer clinical discussions, and participation in denials management which include review of previous clinical decisions by Priority Health Medical Directors (appeals). There will be opportunities to clinically contribute to discussions specific to populations health topics. Expectation to maintain Board Certification in a Medical or Surgical specialty from a nationally recognized specialty board. This position will be a strong contributor to support the mission and vision of Priority Health.
Essential Functions
Understand Priority Health's mission, strategic goals, and value proposition for our communities and the people we serve.
Actively participate in support of medical management
Provide clinical oversight to nurse case management and utilization management.
Promote and advocate for patient-centered care, evidence-based medicine, and lower per-capita costs; participate in the development of clinical utilization guidelines, health management programs and clinical quality programs.
Promote evidence-base care standards with our community physician partners.
Qualifications
Required Doctorate
3 years of relevant experience in clinical setting. Required
3 years of relevant experience Managed care experience. Required
Proven experience and evidence of success in effective physician communication and education skills; evaluation of evidence-based standards of care and application of utilization management skills and strategies. Preferred
LIC-Physician (MD) - State of Michigan required Or
LIC-Osteopathic Physician (DO) - State of Michigan required within 90 days. Required.
Board Certification DO - AOA American Osteopathic Association upon hire Required OR
Board Certification MD - AMBS American Board of Medical Specialties upon hire Required OR
Board Certification MD_DO - AAHPM American Academy of Hospice & Palliative Medicine upon hire Required OR
Board Certification MD_DO - ABFAS American Board of Foot & Ankle Surgery upon hire Required OR
Board Certification MD_DO - ABOMS American Board of Oral & Maxillofacial Surgery upon hire Required OR
Board Certification MD_DO - ABPM American Board of Podiatric Medicine upon hire Required OR
Board Certification MD_DO - ABSM American Board of Sleep Medicine upon hire Required OR
Board Certification MD_DO-ABAM American Board of Addiction Medicine upon hire Required OR
Board Certification MD_DO-ASAM American Society of Addiction Medicine upon hire Required
Working knowledge of national utilization management tools such as InterQual and Milliman. Preferred
How Corewell Health cares for you
Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here .
On-demand pay program powered by Payactiv
Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!
Optional identity theft protection, home and auto insurance
Traditional and Roth retirement options with service contribution and match savings
Eligibility for benefits is determined by employment type and status
Primary Location
SITE - Priority Health - 1231 E Beltline Ave NE - Grand Rapids
Department Name
Medical Affairs - PH Managed Benefits
Employment Type
Full time
Shift
Day (United States of America)
Weekly Scheduled Hours
40
Hours of Work
8 a.m. to 5 p.m.
Days Worked
Monday to Friday
Weekend Frequency
Variable weekends
Company safety statement
Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MM
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Worksite address
grand rapids, MI, 49528, US
Who can apply
Review the original listing for work authorization, qualifications and employer requirements.