Provides clinical expertise and guidance to the daily operations and administration of medical management for CHOICE Health Plans. Assists senior leadership in planning, directing and coordinating all medical and related activities. Participates in implementing standards of medical service and advises senior leadership on medical and administrative questions and policies as they relate to the CHOICE population. Investigates and implements new medical policies based on clinical expertise, in depth data analysis and interpretation designed to improve clinical outcomes. . Serves as consultant for unusual and difficult medical cases. Participates in the QARR/HEDIS Quality Improvement Activities and utilization management of the population. Works under limited direction.
- Provides oversight of VNSNY CHOICE clinical components for utilization review and decision making.
- Leads in establishing medical policies for CHOICE; collaborates in the designs and implementation of advanced care/case management strategies; and communicates, as needed, with providers to ensure effective quality care is being provided.
- Reviews utilization and care management data; identifies trends and needs of the program population; and collaborates with Medical Management leadership to develop and implement plans to meet needs.
- Provides guidance and consultative services to Utilization Management (UM) and Care Management (CM) staff on issues relating to clinical services, case management, condition management, and health risk assessments. Develops solutions for complex cases, reviews prior authorizations/denial of services, and grievances and appeals. Participates in weekly care management/UM rounds for products, as applicable. Performs audits of other UM/CM physician peer reviewers.
- Provides leadership to the Quality Improvement Program and advises CHOICE leadership on the adoption and enforcement of polices concerning medical services for CHOICE membership.
- Ensures compliance with relevant and applicable federal, state and local laws and regulations. Works with Compliance and Special Investigation Unit on issues related to Fraud, Waste, and Abuse of Medicare/Medicaid services.
- Collaborates with pharmacy services to review PBM activities and denial of prior authorizations, implementation of new government program policies and the monitoring for fraud, waste, abuse of drugs. Educates pharmacists on adherence, inappropriate prescribing or duplicative services. Ensures proper communication established between prescribers, MCO and pharmacists for member medication reconciliation/review.
- Ensures that CHOICE and program guidelines are adhered to in measuring adequacy, appropriateness and effectiveness of plan of care; assists in evaluating program and member service policies and procedures to help develop ways to enhance effective delivery of care and member/provider satisfaction.
- Acts as a representative of CHOICE and an advocate for the community through liaison, lecturing and promotional activities. Attends external meetings, seminars, and conferences to promote sharing of expertise and educate consumers and external providers regarding CHOICE service model.
- Establishes and fosters ongoing communication with providers in the VNSNY CHOICE network to understand their barriers to delivering quality care; collaborates with providers in discussing options available to help maintain best standards in practice.
Licensed to practice medicine in New York State required. Multi-state licensure preferred. Board Certification in internal or family medicine preferred. Certification in Geriatric Care preferred.
Minimum five years of experience in clinical medicine, including three years in managed care, and application of evidence based medical necessity criteria and CMS guidance required. Prior experience in geriatric medicine preferred. Prior experience in a Medical Services Organization preferred. Demonstrated strong knowledge of Medicare and Medicaid regulatory and reporting requirements required. Strong communication and influential skills required. Exceptional leadership, critical thinking and decision-making skills preferred.
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