The Senior Medical Director (MD) is responsible for providing clinical expertise in support of population health and medical management programs to promote the delivery of high quality, cost-effective, constituent responsive medical care for the populations and the networks that we manage. The Senior Medical Director is a critical medical and business leader participating in the overall medical and quality management for RWJBH Population Health, as well as the contact for external providers and related constituencies. As part of the medical director leadership team, the Senior MD will partner with the Population Health Care Management Team and other RWJBH assets to increase the effectiveness of care management and medical management programs to promote integration among the RWJBH health and medical programs. Additionally, the Senior MD focuses on innovative approaches for improving the quality, efficiency, and appropriateness of care delivered with an eye toward system-wide value enhancements through the institution of best practices, technological solutions, or other enhancements.
- Collaborates with community and employed physicians, staff, and constituencies to support their efforts to improve utilization, quality of care, patients/member experience, medical documentation, etc. for RWJBH Population Health programs.
- Communicates, educates, and develops partnerships with payors and providers (including medical groups and hospital systems) and serves, when needed, as the interface between the RWJBH teams and its constituencies.
- Execute predetermination reviews, reviews of claim determinations, providing clinical, coding, and reimbursement expertise.
- Manage UM transactional work (front line reviews and appeals).
- Oversee utilization review/quality assurance in collaboration with case management.
- Provide UM services based on business demands and shifting business needs.
- Partner with care management and medical management leadership to increase effectiveness of medical management programs and to promote the integration of other medical programs.
- Provide clinical guidance in operating effective medical programs to promote member and patient quality of care and in reviewing potential lapses in the quality of care.
- Proactively use data analysis to identify opportunities for quality and clinical improvement, to positively influence the effective delivery of quality care.
- Work collaboratively with other functional areas and RWJBH assets that interface with medical management
- Act as part of the medical ship team for external payors, providers, and community in general.
- Act to engage providers and facilities in improving the quality, clinical, and cost efficient care delivered to members and patients, while assuring that our shared business relationships are maintained and improved.
- Graduate of an accredited medical school; Doctorate degree in Medicine
- Candidates with post-graduate degrees (e.g., MBA, MPH, MMM) preferred.
- Board certification in an American Board of Medical Specialties (ABMS) recognized specialty
- Active, unrestricted active medical license in New Jersey as a Doctor of Medicine or a Doctor of Osteopathy
- Clinical Practice: 5-10 Years of direct patient care
- 2-3 years of experience in Health Care Delivery System
- 1-2 years of experience in Clinical leadership (ex. quality review, peer review, group/practice management, hospital teams)
- Medical Management or Care Management
- 5+ years of knowledge/experience in managed care (consultant, medical director, discharge planning)
- Interacting with Medical Professionals
- Advanced Leadership
- Driving a Culture of Transformation and Compliance
- Collaborating for Results
Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.
We offer a great work environment, competitive rates and excellent benefits, including:
- Medical/Dental/Vision plans
- 401 (k)
- Vacation/Personal/Holiday/Sick Time Off
- Short & Long Term Disability
- Basic Life & Accidental Death Insurance
- Tuition Reimbursement
- Health Care/Dependent Care Flexible Spending Accounts
RWJBarnabas Health is the most comprehensive health care delivery system in New Jersey and the state s second largest private employer with more than 32,000 employees, 9,000 physicians and 1,000 residents and interns. The system includes eleven acute care hospitals, three acute care children s hospitals and a leading pediatric rehabilitation hospital (Children s Specialized Hospital).
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