Medical Director (Associate Medical Director)
Health Care that Starts with You!
Join a truly mission-driven organization! Independent, nonprofit UCare is recognized as one of the Minnesota's leading health plans. We provide more than 225,000 members across Minnesota and western Wisconsin with the health coverage plans and services they need to maintain and improve their health. The innovative coverage we create makes a difference for Medicare-eligible individuals, individuals and families enrolled in Minnesota Health Care Programs, such as MinnesotaCare and Medical Assistance, and disabled adults with special health care needs. UCare is growing in size, membership, products, geographic coverage, and employees. We're an organization that's going places. Be part of a team that cares about you, be part of UCare.
ABOUT UCAREAt UCare, we deliver high-quality health coverage and services to help members of all ages maintain and improve their health. It's a big job that takes innovative ideas, strategic partnerships, and a commitment to doing the right thing. Above all, it takes a compassionate team that is dedicated to making a real difference in the lives of our members and our communities.WORKING AT UCAREWorking at UCare is more than just a career; it's a mission. A mission that defines us as professionals, unites us as an organization, and shapes how we interact with our members and each other. Our values of integrity, community, quality, flexibility, and respect permeate every aspect of our organization - from who we are and how we act, to what we do and how we do it. We owe our continued success to our employees who proudly embody our mission and values in everything they do. MEDICAL DIRECTOR (ASSOCIATE MEDICAL DIRECTOR)
Position DescriptionThis position is responsible to conduct day-to-day medical management and lead ongoing improvement in collaboration with CMO. Provide support and consultation for utilization management (medical, pharmacy, behavioral health), appeals, medical policy (development and maintenance), and quality improvement (Medicare Stars, NCQA). Ensure that UCare members receive care that is safe, timely, effective, efficient, patient-centered, and equitable Support and help to lead aspects of regulatory compliance that relate to clinical functions and programs. Provide clinical support as needed to staff throughout UCare: e.g., complex case management, disease management, vendors and delegates. Represent UCare in externally forums: e.g., Council of Health Plans, ICSI, and Community Measurement. Key collaborative relationships: Medical Directors, Associate Medical Directors, Chief Nursing Officer, Vice President of Quality and Pharmacy Director. Specific duties and responsibilities include: 1. Perform medical reviews for determinations of medical necessity, by applying formal clinical criteria that have been adopted by UCare·Reviews may be pre-service authorizations (PA), post-service reviews, and appeals·Scope encompasses medical and surgical procedures, diagnostic testing, facility admissions and length-of-stay, pharmacy, DME, behavioral health, home care·Assure that workload is distributed fairly among the medical directors and turnaround times (TAT) are met·Document clearly the rationales for clinical decisions, based upon the medical necessity criteria adopted at UCare. Articulate decisions in a manner that is readily understood by medical practitioners and members, is audit-ready all the time, with high inter-rater reliability·Conduct peer-to-peer conversations (typically by phone) with practitioners in the community when needed to adjudicate cases·Select cases needing to be referred to an external review organization·Support Clinical Services case managers for complex cases needing input and advice from a physician 2. Collaborate with and support the staff of Clinical Services and Quality Management to continuously improve processes: avoid errors and rework, improve consistency and reliability, and avoid unnecessary delays 3. As directed by the CMO, assume responsibility for the medical directors' administrative budget (e.g., external reviewer services, software, subscriptions, meetings and travel). Medical Director responsibility. 4. Participate in committees as assigned: External committees:·Pharmacy and Therapeutic Committee*·Credentialing Committee*·Quality Improvement Advisory and Credentialing Committee
Internal UCare committees·Medical Policy Committee*·Medical Management Committee·Quality Improvement Committee·Reimbursement and Contracting·Compliance*May chair 5. Support Pharmacy Department in the development and implementation of formularies, PA criteria and processes, and initiatives to promote safe and cost-effective utilization of pharmaceuticals 6. Investigate instances of possibly substandard quality-of-care according to the process coordinated by the Clinical Services department. Serve as the UCare medical officer who requests a formal response from the responsible provider. Medical Director responsibility. 7. Collaborate with and support QM to support company-wide clinical quality imperatives: Medicare Stars, NCQA, PIPs and QIPs. 8. Assist in problem-solving and the planning and execution of initiatives·Reduce medical and administrative cost·Improve clinical and service quality for member and providers·Grow membership·Provider Relations initiatives may involve direct interaction with clinical leadership at provider organizations (specialty groups, provider systems, hospitals) 9. Collaborate effectively and provide clinical input when requested by departments outside of Clinical and Quality including Health Care Economics, Provider Relations and Contracting, Health Promotion, Claims and Operations 10. Represent UCare in matters of health care management and quality of care in externally forums: e.g., Council of Health Plans, ICSI, Community Measurement 11. Other project and duties as assigned.
EducationCurrent unrestricted medical license in Minnesota as a Doctor of Medicine (MD or DO) is required throughout employment at UCare. Current Board Certification in a specialty recognized by the American Board of Medical Specialties (ABMS).
Required ExperienceFive years medical practice (after residency) for Medical Director role; will consider less experience for Associate Medical Director role. Demonstrated experience or formally documented education/training in at least two of the following areas (more is highly desirable and required for Medical Director role): · quality improvement· utilization management or medical cost control· complex case management performed in teams· population health· clinical practice guideline development and implementation· healthcare informatics and analytics
Preferred ExperienceExperience in a managed care organization (health plan, medical management company, ACO network) as a medical director or clinical leader.THE UCARE DIFFERENCEUCare is proud to be a recognized Star Tribune Top Workplace for the 8th consecutive year. As a part of our collaborative team, you'll experience the rewards that come with helping others and seeing the positive results of your hard work. We value and respect each individual's ideas and contributions, and give you the freedom to grow both personally and professionally. We are centrally located, and offer onsite education, equipment and wellness resources, a myriad of volunteer activities, and a number of other rewards. If you're looking for a welcoming environment that celebrates what you have to offer, helps you build on your strengths, and gives you the opportunity to truly make a difference, we invite you to apply. As an Equal Opportunity/Affirmative Action Employer, we welcome and employ a diverse employee group committed to meeting the needs of UCare, our members, and the communities we serve.
Enter a highly collaborative environment where people are truly engaged, and feedback is valued. You'll enjoy a competitive salary and benefits, as well as a host of other perks, including a nationally recognized wellness program, and a bright, open, award-winning office space in Northeast Minneapolis just minutes from major freeways and retail centers.
At UCare, we welcome and employ a diverse employee group committed to meeting the needs of UCare, our members, and the communities we serve.