Medical Director (43921)

The Medical Director is to provide clinical leadership and consultation to the Plan’s various departments with the goal of promoting clinical excellence, quality care in our provider network, as well as maximizing member access to care and satisfaction in health care services.

Duties and Responsibilities

Responsibilities include, but are not limited to the following:

• Work closely with the CMO to establish a clinical strategy to meet the medical management PMPM performance targets while promoting quality healthcare for the plan’s members.
• Oversee the Associate Medical Directors and Medical Consultants to ensure that all departments of the plan have access to physician input. This includes providing clinical expertise during established rounds, and on an as needed basis for clinical programs including case management, disease management or any other clinically based programs.
• Provide oversight of the scheduling, payroll, and budget for the Medical Director Department.
• Ensure that clinical expertise is maintained in the Medical Review process by establishing processes and target expectations for inpatient and outpatient utilization review. These activities include…
• Serve as Chair/ oversight of the Pharmacy and Therapeutics committee.
• Serve as Chair of the Utilization Management Committee. This includes ultimate oversight of Clinical Medical Policies.
• Provide oversight to the AMD running the Clinical Affairs Committee.
• Provide oversight and input regarding benefit guidelines.
• Perform any review of pharmacy or medical requests for non-covered services/products.
• Ensure that all regulatory expectations of the review processes are followed by coordination with the Compliance and GAU departments.
• Provide full support for quality initiatives.
• Oversight of the Quality Assurance Committee process including review of cases with the staff/nurse assisting with the review.
• Participation in the NCQA Readiness, D-SNP Quality Committee, & Medicaid and Commercial Quality Committee
• Provide management oversight of the Credentialing Team and Health @ Home Team.
• Provide or facilitate clinical expertise for the following functions:

• Credentialing activities, including approval and re-approval processes.
• Fraud, waste and abuse activities.
• Behavioral Health management with oversight of the BH medical director.
• Care Management
• Work closely with the Pharmacy team to participate in the oversight of the plan’s PBM.

• Participate in any needed preparation and presentation of regulatory and accreditation review. This work includes representing Neighborhood at any State Fair hearings or Administrative Law Judge activities.

• Engage in on-going performance management of staff including coaching, mentoring, development,
  • Training and succession planning to include hiring and termination decisions.
• In coordination with the CMO, represent Neighborhood in internal and external meetings and forums with
  • Providers, vendors, and regulators. This includes the management of the interactions with the regulatory bodies (OHIC/EOHHS/CMS) as well as statewide stakeholders such as CTC, PCMH Kids.
• Active participation on the Medical Cost Action Committee by developing and sponsoring the initiation of measures to control medical cost.
• Perform other duties as assigned
• Corporate Compliance Responsibility - As an essential function, the Medical Director is responsible for complying with Neighborhood’s Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents.