|Title:||Provider Analytics - Director|
|Job Location:||Chicago, Illinois - United States|
|Salary:||$190,000.00 - $270,000.00 - US Dollars - Yearly|
|Employer Will Recruit From:||Nationwide|
Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit.
Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities.
Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services.
Supports effective implementation of performance improvement initiatives for capitated providers.
· Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members.
Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements.
Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership.
Oversees the activities of physician advisors. Utilizes the services of medical and pharmacy consultants for reviewing complex cases and medical necessity appeals.
Participates in provider network development and new market expansion as appropriate. Assists in the development and implementation of physician education with respect to clinical issues and policies.
· Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components. Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care. Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality. Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment.
· Develops alliances with the provider community through the development and implementation of the medical management programs. As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues. Represents the business unit at appropriate state committees and other ad hoc committees
Responsible for the provider performance program by persuading physician groups, local markets and medical staff of the value of the program for members improved quality of care, lower cost of services and improved financial reimbursement for providers who are successful in managing quality, access and overall costs.
Monitors competitor products and internal provider performance reporting capabilities and responds with recommended enhancements
Accountable for achieving performance results in value based care by engaging, influencing and supporting physicians. Engages with providers in joint operating committees and builds relationships with clinical leadership of provider collaboration groups.
Responsible for collaborating with providers in a region.
Board certification through American Board Medical Specialties. Current state medical license without restrictions. Medical Doctor or Doctor of Osteopathy, board certified preferable in primary care specialty (internal medicine, family practice, pediatrics or emergency medicine). Actively practicing physician; willing to travel within the State of IL
Previous experience within a managed care organization (MCO)
Must have provider strategy, provider performance analytics experience.
Hospital leadership and/or community outreach experience a plus.
University - MD